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Fistula Enterokutaneus

Definisi
Fistel berarti adanya hubungan abnormal antara dua pemukaan berepitel. 1
Berdasarkan atas hubungan dengan dunia luar, maka fistel dibagi menjadi 2 bagian yaitu
fistel internal dan fistel eksternal. Fistel internal adalah fistel yang menghubungkan dua
bagian tubuh yang kedua-duanya masih berada dalam tubuh, contohnya fistel vesicorectal,
fistel rektovaginal, fistel vesikokolik. Sedangkan fistel eksternal dimaksudkan pada fistel
yang salurannya menghubungkan antara organ dalam tubuh dengan dunia luar, contohnya
fistel enterokutaneus.2
Fistula enterokutaneous adalah suatu saluran abnormal yang menghubungkan antara
traktus gastrointestinal dan kulit. Fistula Enterokutaneus atau Enterocutaneus Fistula (ECF)
adalah adanya hubungan abnormal yang terjadi antara dua pemukaan berepitel yaitu antara
saluran cerna dengan kulit.
An ECF can arise from the duodenum, jejunum, ileum, colon, or rectum. Although
fistulas arising from other regions of the gastrointestinal (GI) tract (eg, stomach and
esophagus) may sometimes be included in the definition of ECF, the discussion in this article
is limited to the conventional definition of ECF. A fistula-in-ano, though anatomically an
ECF, conventionally is not referred to as such, because its presentation and management are
different.3
KLASIFIKASI
Classification of fistulas is by no means standard. There are three usual classification
systems, and most fistulas benefit from being described using all of them at once 4. The
anatomic classification names the fistula using the organs involved. By convention, the
highest pressure system is named first, for example, a gastrocutaneous fistula. The anatomic
classification may also include a description of the fistula tract, such as complex versus
simple, or long versus short, and a description of the bowel defect, usually measured as
greater or less than 1 cm.
Berdasarkan kriteria fisiologi, fistula enterokutaneous dibagi menjadi 3 yaitu highoutput, moderate-output dan low output.

Fistula enterokutaneous dapat menyebabkan

pengeluaran cairan intestinal ke dunia luar, dimana cairan tersebut banyak mengandung
elektrolit, mineral dan protein sehingga dapat menyebabkan komplikasi fisiologis yaitu

terjadi ketidak-seimbangan elektrolit dan dapat menyebabkan malnutrisi pada pasien. Fistula
dengan high-output apabila pengeluaran cairan intestinal sebanyak >500ml perhari,
moderate-output sebanyak 200-500 ml per hari dan low-output sebanyak <200 ml per hari.
The etiologic classification names fistulas by their associated disease processes, for
example, a diverticular fistula or a neoplastic fistula. These classification systems can be used
to estimate the mortality and the chance of spontaneous closure of a fistula. Mortality is five
times greater for high-output fistulas than lowoutput fistulas. Table 1 gives examples of
fistula characteristics that predict the likelihood of the fistula closing spontaneously.
Table 1 Effect of Fistula Characteristics on Likelihood of Spontaneous Closure
More Likely to Close
Less Likely to Close
Anatomic
Jejunal
Ileal
Tract <2 cm
Tract >2 cm
Bowel defect <1 cm2
Bowel defect >1 cm2
Epithelealized tract
Distal obstruction
Etiologic
Appendicitis
Neoplastic
Diverticulitis
Inflammatory bowel
Postoperative
disease
Radiation
Foreign body

Fig. 2 a Multiple enterocutaneous fistulas.


Etiologi
Fistula enterokutaneous dapat disebabkan oleh pasca operasi, atau spontan.
Kebanyakan fistula terjadi oleh karena infeksi pada saluran cerna, kanker ataupun lisis dari
anastomosis saluran cerna dan radiasi. Berdasarkan proses terjadinya 2 jenis :
-

Spontan
Komplikasi pasca operasi ( 70 95 % )

1) FEK Spontan
Fistula yang terjadi secara spontan, terjadi sekitar 15-25% dari seluruh fistula
enterokutaneous. Jenis fistel ini biasanya terbentuk sebagai hasil perjalanan kronis

suatu penyakit. Fistula ini dapat disebabkan oleh berbagai hal, diantaranya:
Inflamatory Bowel Disease ( 5% -50%)
Radiasi (5% - 10%)
Keganasan ( 2% -15%)
Divertikulitis
Apendisitis

2) Penyebab FEK Pasca Operasi


Penyebab utama fistula enterokutaneous adalah akibat komplikasi postoperasi (sekitar
75-85%). Faktor penyebab timbulnya fistula enterokutaneous akibat postoperasi dapat
disebabkan oleh faktor pasien dan faktor tehnik. 4 Faktor pasien yaitu malnutrisi,
infeksi atau sepsis, anemia, dan hypothermia.Sedangkan faktor tehnik yaitu pada
tindakan-tindakan preoperasi. Sebelum dilakukan operasi, harus dievaluasi terlebih

dahulu keadaan nutrisi pasien karena kehilangan 10-15% berat badan, kadar albumin
kurang dari 3,0 gr/dL, rendahnya kadar transferin dan total limposit dapat
meningkatkan resiko terjadinya fistula enterokutaneous. Selain itu, fistula
enterokutaneous dapat disebabkan oleh kurangnya vaskularisasi pada daerah operasi,
hipotensi sistemik, tekanan berlebih pada anastomosis, dan membuat anastomosis dari
usus yang tidak sehat. Untuk mengurangi resiko timbulnya fistula, keadaan pasien
harus normovolemia / tidak anemis agar aliran oksigen menjadi lebih optimal.Selain
itu pada saat operasi harus diberikan antibiotik profilaksis untuk mencegah timbulnya
infeksi dan abses yang dapat menimbulkan fistula.

Faktor predisposisi : leakage anastomosis, abses, obstruksi pada distal


Penyebab timbulnya fistula enterokutaneous akibat postoperasi dapat disebabkan
oleh:

1. Kebocoran anastomosis
2. Inadvertent enterotomy - Occurs especially in patients with adhesions, when
dissection can cause multiple serosal tears and an occasional full-thickness tear.4

Fig. 1. Inadvertent enterotomy during lysis of adhesions may effect of the fistula
allows all obstructive features to subside.
3. Inadvertent small-bowel injury - Occurs during abdominal closure, especially after
ventral hernia repair.
Kebocoran anastomosis dapat terjadi karena aliran darah yang tidak adekuat yang
disebabkan pasokan vaskular tidak layak, terutama ketika pembuluh mesenterika yang
ekstensif harus diikat. Disruption of anastomosis can result from inadequate blood flow due
to an improper vascular supply, especially when extensive mesenteric vessels have to be

ligated. Tension on anastomotic lines following colonic resection, restoration of continuity


without adequate mobilization, or a minimal leak or infection can lead to perianastomotic
abscess formation, resulting in disruption, as seen in patients with anterior resection for rectal
carcinoma. In addition, if anastomosis is performed in an unhealthy bowel (eg, diseased,
ischemic), it can lead to disruption and cause an ECF.
Inadvertent picking up of the bowel during abdominal closure can result in a small-bowel
fistula; this especially can occur with the use of open inlay mesh or intraperitoneal onlay
mesh repair by the laparoscopic method, when the viscera comes in contact with the mesh,
leading to adhesions and sometimes to disruption.
A colocutaneous fistula can develop after colonic surgery, especially when the blood supply
to a low colorectal/anal anastomosis is compromised or when there is tension at the
anastomotic suture line. This type of fistula can also result from diseases of the colon, such as
IBD or malignancy leading to perforation, pericolic abscess formation, and ECF. Surgery for
appendicitis, appendicular perforation at the base, or drainage of an appendicular abscess can
also lead to a colocutaneous fistula. Radiation therapy is also another major cause of colonic
fistula.[3] In rare cases, migration of a polypropylene or composite mesh from a hernia repair
can lead to ECF formation[4, 5]

Gambar... fistula enterokutan yang di sebabkan oleh kebocoran anastomosis


GEJALA/MANIFESTASI KLINIS
Gejala awal dari fistula enterokutaneous adalah demam, leukositosis, prolonged ileus,
rasa tidak nyaman pada abdomen, dan infeksi pada luka. Diagnosis menjadi jelas bila
didapatkan drainase material usus pada luka di abdomen.
Diagnosis fistula enterokutan biasanya dinilai dari drainase eksternal isi usus yang
seringkali timbul pada hari kelima atau keenam pasca operasi disertai dengan gejala demam,
ileus yang menetap dan abses pada luka operasi.

PEMERIKSAAN PENUNJANG
Pemeriksaan penunjang pada kasus Fistula yaitu sebagai berikut:
a. Pemeriksaan Laboratorium
The following laboratory studies are performed in the evaluation of an
enterocutaneous fistula (ECF):

Total leukocyte count - This is important because sepsis can lead to leukocytosis
Serum sodium, potassium, and chloride levels - Electrolyte abnormalities can result

from fluid and electrolyte loss


Complete blood count (CBC), total proteins, serum albumin, and globulin - These can

demonstrate the presence of malnutrition-associated anemia/hypoalbuminemia


Serum transferrin - Low levels (<200 mg/dL) are a predictor of poor healing
Serum C-reactive protein - Levels may be elevated

b. Non absorbable marker per oral


Oral administration of a nonabsorbable marker (eg, charcoal, Congo red) can help
confirm the presence of an ECF.
Methylene blue diluted in saline can be administered through a nasogastric tube as
a simple bedside test to confirm the presence of an ECF, especially in patients with a
gastrocutaneous or lateral duodenal fistula. This test can also help to determine whether
the leak is from a segment that is in the continuity of the gastrointestinal tract, especially
in the case of proximal fistulas. However, because methylene blue loses diagnostic
efficacy as it becomes diluted with intestinal secretions, its role in identifying distal ECFs
is limited.
c. Fistulografi
Tehnik ini menggunakan water soluble kontras. Kontras disuntikkan melalui
pembukaan eksternal, kemudian melakukan foto x-ray. Dengan menggunakan tehnik
pemeriksaan ini, dapat diketahui berbagai hal yaitu : Sumber fistula, jalur fistula, adatidaknya kontinuitas usus, ada-tidaknya obstruksi di bagian distal, keadaan usus yang
berdekatan dengan fistula (striktur, inflamasi) dan ada-tidaknya abses yang berhubungan
dengan fistula.

Fistulogram menunjukkan enterocutaneous fistula.

Fistulogram showing a colocutaneous fistula following anastomotic leak after


colostomy closure.
d. USG
USG dapat digunakan untuk mengetahui ada-tidaknya abses dan penimbunan
cairan pada saluran fistula.
e. Barium enema

Pemeriksaan ini menggunakan kontras, untuk mengevaluasi lambung, usus halus,


dan kolon. Tujuannya untuk mengetahui penyebab timbulnya fistula seperti penyakit
divertikula, penyakit Crohn's, dan neoplasma.
f. Water-soluble contrast enema
The different types of tracts that can be seen by using a water-soluble contrast
enema (WCE) in patients with ECF with failure of low colorectal anastomosis may be
classified as follows[16] :

I Simple, short blind ending, <2 cm


II - Continuous linear, long single, >2 cm
III - Continuous complex, multiple linear

Tract positions are as follows:

Anterior - Ventral, 10-oclock to 2-oclock position


Posterior - Dorsal, 4-oclock to 8-oclock position
Lateral - Right (2-oclock to 4-oclock position) or left (8-oclock to 10oclock position)

Additional tract features seen with a WCE include the cavity (pooling of contrast
within space) and/or a stricture (narrowing of anastomosis, with hold of contrast). The
presence of a stricture and a large cavity on WCE predicts failure of healing.
g. CT scan: mengetahui underlying disease
Computed tomography (CT) is useful for demonstrating intra-abdominal abscess
cavities. Such cavities can occur if an ECF has an indirect tract when it first drains into an
abscess cavity and then drains to the exterior cavity. If an ECF is associated with intraabdominal sepsis, then interloop abscesses may be present.
PENATALAKSANAAN
Penatalaksanaan ditujukan untuk mengontrol komplikasi berupa sepsis, syok
hemodinamik, gangguan keseimbangan cairan dan elektrolit, malnutrisi serta mengurangi
jumlah ouput fistula dengan pemasangan nasogatric tube, pemberian antagonis H2 atau
proton pump inhibitor dan drainase abses, koreksi keseimbangan cairan, elektrolit dan
nutrisi serta penggunaan somatostatin atau ocreotide untuk menghambat sekresi gaster,
pankreas, sistem bilier dan usus. Terapi definitif ditujukan bila keadaan pasien tidak
membaik dengan terapi selama 4 sampai 6 minggu melalui operasi dengan menjahit ulang
fistula, reseksi fistula, laparotomi dan penutupan fistula dengan vakum atau lem fibrin.

Tujuan penanganan fistula

Mengembalikan kontinuitas usus


Mencapai pemberian nutrisi oral
Penutupan fistula

Penatalaksanaan fistula enterokutaneous dapat dibagi menjadi 5 tahapan, yaitu


stabilization, investigation, decision making, definitive therapy, dan healing.
1. Stabilization
Tahap ini dibagi menjadi 5 yaitu: identification, resuscitation, control of sepsis,
nutritional support, control of fistula drainage
a. Identification
Pada tahap ini, yang dilakukan adalah mengidentifikasi pasien dengan fistula
enterokutaneous. Pada minggu pertama postoperasi, pasien menunjukkan tanda-tanda
demam dan prolonged ileus serta terbentuk erythema pada luka. Luka akan terbuka dan
terdapat drainase cairan purulen yang terdiri dari cairan usus. Pasien dapat mengalami
malnutrisi yang disebabkan karena sedikit atau tidak diberikan nutrisi dalam waktu lama.
Pasien dapat menjadi dehidrasi, anemis, dan kadar albumin yang rendah.
b. Resuscitation
Masalah keseimbangan cairan dan elektrolit yang harus di koreksi pasa pasien
dengan fistula enterkutaneus adalah dehidrasi, hiponatremia dan hipokalemia serta
asidosis metabolik. Tujuan utama pada tahap ini yaitu pemulihan volume sirkulasi. Pada
tahap ini, pemberian kristaloid dibutuhkan untuk memperbaiki volume sirkulasi.
Transfusi sel darah merah dapat meningkatkan kapasitas pengangkutan oksigen dan
pemberian infuse albumin dapat mengembalikan tekanan onkotik plasma.
c. Control of sepsis
Pada tahap ini, melakukan pencegahan terhadap timbulnya sepsis dengan
pemberian obat antibiotik.
Sepsis yang tidak ditangani merupakan penyebab kematian utama pada pasien
dengan fistel enterokutan. The control of any septic foci should begin when the patient is
sufficiently stable to undergo diagnostic and therapeutic intervention. Computed
tomography (CT) is the best test for elucidation of intraperitoneal abscesses, which can
then be drained. In a stabilized patient, these collections are preferentially drained
percutaneously by an experienced interventional radiology team. Alternately, the abscess
can be drained through the fistula tract with a sump drain, with the tip of the drain placed

near the enteric opening. Again, this should be done by an experienced interventional
radiology team under fluoroscopic guidance with fistulography.12 While draining the
abscess collection, cultures should be sent. If the patient is septic, broad-spectrum
antibiotics should be started with the intent to narrow antibiotic coverage as culture
results permit. A patient with an ECF without fevers, tachycardia, or signs of local
infection such as cellulitis does not need antibiotics. A patient with severe sepsis
unresponsive to resuscitation or with an abscess unable to be percutaneously drained may
need an urgent return to the operating room for washout of the abdominal cavity and
control of the fistula. In this case, the best management is often a diverting proximal
stoma.13 In most patients who are hemodynamically stable after resuscitation, the
optimal treatment is to delay a return trip to the operating room and control sepsis through
antibiotics, drainage, and supportive care. The post surgical abdomen 1 week after
laparotomy is an inhospitable arena where dense adhesions and friable, edematous bowel
make reoperation difficult and increase the chance of further complications. Avoidance of
reoperation at this time, when possible, is imperative.
d. Nutritional support
Pemberian nutrisi pada pasien dengan fistula enterokutaneous merupakan
komponen kunci penatalaksanaan pada fase stabilization. Fistula enterokutaneous dapat
menimbulkan malnutrisi pada pasien karena intake nutrisi kurang, hiperkatabolisme
akibat sepsis dan banyaknya komponen usus kaya protein yang keluar melalui fistula.
Pasien dengan fistula enterokutaneous membutuhkan kalori total sebanyak 25-32 kcal/kg
perhari dengan rasio kalori-nitrogen 150:1 sampai 200:1, protein minimal 1,5g/kg perhari.
Selain itu, perlu diberikan elektrolit dan vitamin seperti vitamin C, vitamin B12, zinc,
asam folat.
e. Control of fistula drainage
Terdapat berbagai tehnik yang digunakan untuk managemen drainase fistula yaitu
simple gauze dressing, skin barriers, pauches, dan suction catheter.
Selain itu, untuk mencegah terjadinya maserasi pada kulit akibat cairan fistula,
dapat diberikan karaya powder, stomahesive atau glyserin.Beberapa penulis melaporkan
keberhasilan

menggunakan

Vacuum

Assisted

Closure

(VAC)

system

untuk

penatalaksanaan fistula enterokutaneous. Obat-obatan (Somatostatin, Octreotide dan H2


Antagonis) dapat juga diberikan untuk menghambat sekresi asam lambung, sekresi
kelenjar pankreas, usus, dan traktus biliaris.x

For a high-output fistula, a pouch system is preferable to a conventional skin


dressing. For a low-output fistula, a skin barrier with a dressing or pouch is advocated.
When the fistula output is high, it is desirable to use a pouch for collecting the
enteric effluents. Ostomy pouches in one- or two-piece designs with either a drainable
clip or a urostomy-type closure can be cut and fit to perifistular skin. If the area of the
fistula is on an irregular body contour (eg, close to bony prominences), then a one-piece
pouch is more suitable because it can adhere better.
A transparent pouch is preferred to an opaque pouch, for visualization of the
fistula. A pouch with a skin-barrier backing is more durable than one with an adhesive
backing. Wound manager bags (see the image below) are preferable in that they are
specifically designed to help make wound care easier with good skin protection and
access to the wound for its care.

The degree of skin irritation present (from erythema to maceration to skin loss)
guides the type of skin-protecting agents that should be applied and the type of pouch
system that should be used. In addition, an important consideration is whether the
opening is flush with the skin, retracted and deep, close to bony prominences, or in an
open wound.
Skin barriers

Powder, paste, wafers, spray, and creams are used as skin barriers for the
protection of skin from the enteric effluents.
Pectin-based wafers that melt and seal with the skin provide a good barrier and
offer protection for a variable period before the skin breaks down and ulcerates. In lowoutput fistulas, absorbent dressings can be put on top of the skin-barrier wafer to absorb
any effluent overflow. The skin wafer protects the adjoining skin from erythema and
maceration.
Pectin- or karaya-based powders and paste are used. Powders are preferred over a
paste in wet, weepy, perifistular skin when severe skin maceration is present. A generous
amount of powder should be used and continuously added for good results. In patients
with weepy skin and a high-output fistula, management becomes difficult.
A spray provides a protective film and is helpful for pouching, but it might not be
beneficial if used alone.
Zinc creams (see the images below) are used to waterproof and protect the skin.
Again, a generous amount with continuous replacement is necessary because the cream is
washed away with discharging enteric effluents.

Zinc oxide cream for skin protection.

Zinc oxide cream barrier around enterocutaneous fistula, with the fistula opening
seen.
Control of fistula drainage
The fistula tract is intubated with a drain (see the image below). Volume depletion
from a proximal high-output fistula can be controlled with the use of the long-acting
somatostatin analogue octreotide, which acts by inhibiting GI hormones. The
administration of octreotide reportedly diminishes fistula output, but whether it shortens
the time required for fistula closure remains to be determined.[26]

Intubation of fistulous tract with drain.

Draus et al recommended a 3-day trial of octreotide, maintaining that if the fistula


output is reduced during this time, then administration of the drug should be continued.
[27] (Octreotide use is associated with an increased incidence of cholelithiasis.[10] ) Two
meta-analyses showed that somatostatin and its analogues decreased the time for fistula
closure and increased the closure rate.[28, 29]However, there was no significant change
in the mortality with the use of somatostatin or its analogues.
Hyon et al reported on a vacuum-sealing method to reduce output, in which a
semipermeable barrier was created over the fistula by vacuum packing a synthetic,
hydrophobic polymer covered with a self-adherent surgical sheet. To set up the system,
the investigators built a vacuum chamber equipped with precision instruments; the
chamber supplied subatmospheric pressures of 350-450 mm Hg. The pressure reduced the
daily fistula output from 800 mL to about 10 mL, thus restoring bowel transit and
physiology.[30]
Draus et al reported that the use of a vacuum-assisted closure (VAC) system for
wounds, which consisted of an evacuation tube embedded in a polyurethane foam
dressing, helped improve the condition of the wound, prevented skin excoriation, and
promoted wound contracture and healing.[27, 31]
2. Investigation
Pada tahap ini, dilakukan investigasi terhadap sumber dan jalur fistula. Ada
beberapa cara yang dapat dilakukan yaitu:
a.
b.
c.
d.
e.

Test methylen blue


USG
Fistulogram
Barium enema
CT scan

3. Decision
Fistula enterokutaneous dapat menutup secara spontan dalam 4-6 minggu pada
pasien dengan pemberian nutrisi adekuat dan terbebas dari sepsis. Penutupan spontan
dapat terjadi pada sekitar 30% kasus. Fistula yang terdapat pada lambung, ileum, dan
ligamentum of Treiz memiliki kemampuan yang rendah untuk menutup secara spontan.
Hal ini berlaku juga pada fistula dengan keadaan terdapat abses besar, traktus fistula yang
pendek, striktur usus, diskontinuitas usus, dan obstruksi distal. Pada kasus-kasus tersebut,
apabila fistula tidak menutup (output tidak berkurang) setelah 4 minggu, maka dapat
direncanakan untuk melakukan operasi reseksi. Pada rencana melakukan tidakan operasi,
ahli bedah harus mempertimbangkan untuk menjaga keseimbangan nutrisi dengan

memberikan nutrisi secara adekuat, kemungkinan terjadinya penutupan spontan dan


tehnik-tehnik operasi yang akan digunakan.
4. Definitive therapy
Sebanyak 50% kasus fistula dapat menutup secara spontan. Faktor-faktor yang dapat
menghambat penutupan spontan fistula yaitu FRIEND (Foreign body didalam traktus fistula,
Radiasi enteritis, Infeksi/inflamasi pada sumber fistula, Epithelisasi pada traktus fistula,
Neoplasma pada sumber fistula, Distal obstruction pada usus). In addition, lateral duodenal,
ligament of Treitz, and ileal fistulas have less tendency to spontaneously close.[10]
Because the possibility of spontaneous closure is reduced in patients with adverse
factors, surgical intervention should be undertaken after a 4- to 6-week trial of conservative
therapy, if no signs of spontaneous closure exist. Surgical procedures in patients with adverse
factors can include draining an abscess, creating stomas by exteriorizing the bowel, or
creating controlled fistulas. When feasible, resection of the fistula with restoration of GI
continuity is performed.
Keputusan untuk melakukan operasi pada pasien dengan fistula enterokutaneous yang
tidak dapat menutup secara spontan adalah tindakan yang tepat.Sebelumnya, pasien harus
dalam kondisi nutrisi yang optimal dan terbebas dari sepsis.
Patients with an almost completely healed wound with a fistulous opening (shown
below) have a good chance of responding to surgical therapy.

Almost healed wound around an enterocutaneous fistula.

Fistula tract being excised.


Pada saat operasi, abdomen dibuka menggunakan insisi baru. Insisi secara
transversal pada abdomen di daerah yang terbebas dari perlekatan. Tujuan tindakan
operasi selanjutnya adalah membebaskan usus sampai rektum dari ligamentum Treiz.
Kemudian melakukan eksplorasi pada usus untuk menemukan seluruh abses dan sumber
obstruksi untuk mencegah kegagalan dalam melakukan anastomosis.
Pada saat isolasi segmen usus yang mengandung fistula, reseksi pada segmen
tersebut merupakan tindakan yang tepat.Pada kasus-kasus yang berat, dapat digunakan
tehnik exteriorization, bypass, Roux-en-Y drainase, dan serosal patches.Namun tindakantindakan tersebut tidak menjamin hasil yang optimal. Berbagai kreasi seperti two-layer,
interrupted, end-to-end anastomosis menggunakan segmen usus yang sehat dapat
meningkatkan kemungikan anastomosis yang aman.
Operative details
In addition to ensuring that patients are stable and free from sources of sepsis before surgical
correction of an ECF is undertaken, antibiotic prophylaxis should be performed and
parenteral nutritional supplementation provided as necessary during the preoperative and the
perioperative periods to achieve good results. Enteral feeding should be decreased to allow
luminal antibiotic preparation. Antibiotic therapy should be administered after the culture
sensitivity of earlier-grown organisms has been checked.[10]
Incision
When performing surgery for an ECF, the author makes a point of always entering the
abdomen through a fresh incision, given that there is a possibility of the gut being adherent to
the site of the incision of the index operation. If the native incision follows a supraumbilical
midline route, then the author takes an infraumbilical midline route and then extends it to the
operative site.

If it is in the middle portion of the midline, then the author makes either an incision in the
midline superior or inferior to the native incision or a transverse incision to approach the
abdomen. The author always enters the peritoneal cavity in a relatively virgin area to lessen
the chance of an inadvertent enterotomy.
Excision and restoration of bowel continuity
Once an assessment is made in the peritoneal cavity, then the entire bowel from the ligament
of Treitz to the rectum is made free of all adhesions. Once this is achieved, the fistulous site is
dissected free from the surrounding structures, and a complete excision is done. The author
prefers to restore bowel continuity by using a two-layer anastomosis, employing interrupted
nonabsorbable suture of healthy and well-vascularized bowel. The author uses it for smallbowel, as well as large-bowel, anastomosis.
An inner layer consisting of continuous absorbable suture and an outer layer consisting of
interrupted nonabsorbable sutures can also be used to restore bowel continuity. Other
alternatives include the use of staplers, especially in low colorectal anastomoses.
Treatment of abscess or diseased bowel
If an abscess or diseased bowel segments are seen, then drainage of the abscess or resection
of the diseased bowel is performed.[9] If the patient is too sick to tolerate a resectional
procedure, then exteriorization of the bowel via ileostomy or colostomy is carried out.
Roux-en-Y drainages or a serosal patch can sometimes be used, especially for a lateral
duodenal fistula following a leak after simple closure of a perforated duodenal ulcer.
[10] However, the results of these procedures are not very encouraging. Converting a lateral
duodenal fistula into an end fistula with a tube duodenostomy is a good option but may not be
possible in most patients.
If anastomosis is performed close to a duodenojejunal flexure, then adequate decompression
by gastrostomy and feeding jejunostomy are carried out. The latter is also performed when
proximal fistula repair is undertaken (eg, lateral duodenal fistula).
Myocutaneous or fasciocutaneous flap
De Weerd et al described the use of a sandwich-design myocutaneous flap cover to close a
high-output ECF.[38] In the initial phase of treatment, the authors used a VAC system for
wound care to promote the development of granulation tissue around the fistulous opening.
The fistula was then closed with serratus muscle from a composite free latissimus dorsi
serratus flap. The large abdominal wall defect was closed with the musculocutaneous
latissimus dorsi flap taken from the composite flap. The placement of a VAC system between
the serratus and the latissimus dorsi helped to fix the serratus to the fistula.
Successful direct repair of an ECF using a surrounding fasciocutaneous flap has also been
reported.[39]
Other Interventions
Use of fibrin glue and plugs
In a study of 10 patients with low-output (n=7) or high-output (n=3) ECFs that had failed
to close after conservative therapy, Rabago et al observed that fibrin glue completely
sealed the majority of ECFs.[41] Once a fistula had been endoscopically located, 2-4 mL
of reconstituted fibrin glue (Tissucol 2.0 at 37C) was injected through a catheter. The
patients required a mean 2.5 treatment sessions (range, 1-5 sessions), and the mean

healing time was 16 days (range, 5-40 days). After treatment, 87.5% of the low-output
fistulas and 55% of the high-output fistulas sealed completely. No complications
occurred.
Truong et al described the use of a Vicryl plug in combination with fibrin glue in the
treatment of ECFs.[42] After the site of an ECF or anastomotic leak was endoscopically
sealed with the plug and glue, seven of the study's nine patients healed completely.
In another study, however, when fibrin glue was introduced directly into an ECF through
the fistula opening in the skin, the results were not encouraging, with the fistula healing
in only one out of eight patients.[27]
Autologous platelet-rich fibrin glue also has been reported to be safe and effective in the
treatment of low-output ECFs by reducing the closure time and promoting closure.[43]
Good results with endoscopic therapy suggest that this technique, when possible, can be
used when other conservative methods fail.
Successful closure of a duodenocutaneous fistula has been reported with the use of the
Biodesign enterocutaneous fistula plug (Cook Medical, Bloomington, IN),which is
derived from a biologic plug used in fistula-in-ano tracts. The plug is introduced into the
fistulous tract percutaneously.[44]
Gelfoam embolization
Lisle et al described successful treatment of three cases of ECF with embolization of
Gelfoam at the enteric opening of the fistula.[45] In this technique, the ECF was assessed
by means of computed tomography (CT) and fistulography to rule out any intraabdominal abscess, distal bowel obstruction, active bowel inflammation, or foreign body
that would prevent the fistula from healing. Fistulography also provided information
about the fistulous tract and the site of communication with the bowel.
A 5-French introducer sheath was passed along a guide wire into the tract under
fluoroscopy and then removed, after which Gelfoam strips or pledgets soaked in contrast
material were introduced into the tract through the sheath and pushed down to plug the
enteric opening of the ECF. All of the patients healed completely, with no recurrence of
ECF over a 2- to 3-year follow-up period.[45]
5. Healing
Penutupan fistula secara spontan ataupun operasi, pemberian nutrisi harus terus
dilakukan untuk menjamin pemeliharaan kontinuitas usus dan penutupan dinding
abdomen. Tahap penyembuhan (terutama pada kasus postoperasi) ini membutuhkan
keseimbangan nitrogen, pemberian kalori dan protein yang adekuat untuk meningkatkan
proses penyembuhan dan penutupan luka.
Antibiotic coverage is needed if the operation is performed in the presence of sepsis. Any
flare-up of sepsis increases the possibility of breakdown of the anastomosis and of the
abdominal wall closure (leading to dehiscence). However, unnecessary use of antibiotics
can lead to resistance and should therefore be avoided.

Fluid and electrolyte balance with appropriate correction is also important, especially in
patients with adverse factors (eg, high-output fistula).
Patients who develop spontaneous fistula due to disease need appropriate therapy (eg,
infliximab for Crohn disease or antituberculous therapy for tuberculosis) during followup to prevent disease recurrence or recurrence of the ECF.[40] In patients with a
malignancy-related ECF, appropriate chemotherapy and radiation, if required, are
administered to control the primary disease.
After healing of a conventional fistula by spontaneous closure, patients should be
informed that because healing occurs with secondary intention, there is a possibility of
development of an incisional hernia as a long-term complication of ECF.
Table ECF Treatment phases
Phase
1.

Recognition

Time Course

Primary goals

and 2448 hours

Correct

stabilization

fluid

and

electrolyte

imbalances
Drainage

of

intra-abdominal

abscesses
Control of sepsis
Control of fistula drainage
Ensure adequate skin care
Aggressive nutritional support
2. Investigation

after 710 days

Determine anatomy and fistula


characteristics

3. Decision

up to 46 weeks

Determine

likelihood

of

spontaneous closure
Plan course of therapy
4. Definitive therapy

after 46 weeks or if closure Closure of fistula


is unlikely
Reestablish

gastrointestinal

continuity
Secure closure of abdomen
5. Healing

510

days

after

closure Ensure adequate nutritional support

onward
Transition to oral intake

KOMPLIKASI

Trias klasik untuk komplikasi yang dapat ditimbulkan oleh fistula enterokutaneous,
yaitu sepsis, malnutrisi, serta berkurangnya elektrolit dan cairan tubuh. Fistula dapat
menimbulkan abses local, infeksi jaringan, peritonitis hingga sepsis. Selain itu, fistula
enterokutaneous dapat meningkatkan pengeluaran isi usus yang kaya akan protein dan cairan
tubuh serta elektrolit sehingga dapat menimbulkan malnutrisi dan berkurangnya kadar
elektrolit dan cairan tubuh. Pemberian nutrisi parenteral (TPN) sangat diperlukan, karena
TPN dapat meningkatkan penutupan fistula secara spontan. Pada pasien yang membutuhkan
penutupan fistula dengan operasi, TPN dapat meningkatkan status nutrisi sehingga dapat
mempertahankan kontinuitas usus dengan cara meningkatkan proses penyembuhan luka dan
meningkatkan system imun.
The degree of sepsis depends on the state of the ECF. If the fistula forms a direct tract
through which the bowel contents are draining onto the skin, then the sepsis may be minimal,
whereas if the fistula forms an indirect tract through which the bowel contents are draining
into an abscess cavity and then onto the skin, the degree of sepsis may be higher. In the
presence of extensive peritoneal contamination or generalized peritonitis with ECF, the
patient can be toxic due to severe sepsis.
Leakage of protein-rich enteric contents, intra-abdominal sepsis, or electrolyte imbalance
related paralytic ileus, as well as a general feeling of ill health, leads to reduced nutritional
intake by these patients, resulting in malnutrition. Nearly 70% of patients with ECFs may
have malnutrition, and it is a significant prognostic factor for spontaneous fistula closure.[13]
Sepsis, malnutrition, and electrolyte imbalance are the predominant factors that lead to death
in patients with ECF.[14] Rarely, intestinal failure can occur as one of the complications of
ECF, which results in significant morbidity and mortality.[15]
A high-output fistula increases the possibility of fluid and electrolyte imbalance and
malnutrition.
PROGNOSIS
Fistula enterokutaneous dapat menyebabkan mortalitas sebesar 5-20%, karena sepsis,
kelainan nutrisi, dan ketidakseimbangan elektrolit (medscape). Mortality was 62% in patients
with gastric and duodenal fistulas, 54% in patients with small-bowel fistulas, and 16% with
colonic fistulas.[2]
Namun, sebanyak 50% kasus fistula dapat menutup secara spontan. Faktor-faktor
yang dapat menghambat penutupan spontan fistula yaitu FRIEND (Foreign body didalam
traktus fistula, Radiasi enteritis, Infeksi/inflamasi pada sumber fistula, Epithelisasi pada
traktus fistula, Neoplasma pada sumber fistula, Distal obstruction pada usus). Tindakan
pembedahan dapat menyebabkan lebih dari 50% morbiditas pada pasien dan 10% dapat
kambuh kembali. Carii lagi