Management of

Enterocutaneous Fistulas

UCSF Postgraduate Course in General Surgery

Maui, HI
March 21, 2011

Hobart W. Harris, MD, MPH

Enterocutaneous Fistulas: Introduction Enterocutaneous Fistulas: Introduction

Fistula: an abnormal communication between two Classification can be based on anatomy, physiology or
epithelialized surfaces. etiology:

Sinus: an abnormal communication between an

epithelialized surface and a source of infection. Anatomy Physiology Etiology

esophagocutaneous low-output (<200 ml/day) Crohns fistula

jejunocutaneous moderate-output (2-500 ml/day) radiation-induced fistula

colocutaneous high-output (>500 ml/day) iatrogenic fistula

 Enterocutaneous Fistulas: Pathophysiology Enterocutaneous Fistulas: Management

Classic Triad of Complications: Goal: To restore the continuity and integrity of the gastrointestinal tract.

Phase Goal Time course

Recognition & Stabilization Fluid & electrolyte repletion 24-48 hours
Control of sepsis
Optimize nutrition
Control fistula output

SEPSIS Investigation
Local skin care & protection
Fistulagram to define anatomy 7-10 days

Decision Evaluate likelihood of spontaneous 10 days-6 weeks

closure
Decide duration of nonoperative
management
ELECTROLYTE Definitive Treatment Plan operative approach; > 6-12 weeks

MALNUTRITION & FLUID Bowel resection, hernia repair,

intestinal diversion, etc.
ABNORMALITIES Healing Continued nutritional support From perioperative period until
Supplementation (vitamins A & C, Zn) fistula resolved

Evenson & Fischer, J Gastrointest Surg 2006;10:455-464a

Enterocutaneous Fistulas: Management Enterocutaneous Fistulas: Management

Goal: To restore the continuity and integrity of the gastrointestinal tract.

Recognition & Stabilization:
Phase Goal Time course
Recognition & Stabilization Fluid & electrolyte repletion 24-48 hours A.) Fluid & electrolyte repletion
Control of sepsis
Optimize nutrition
B.) Control of sepsis
Control fistula output
Local skin care & protection
Investigation Fistulagram to define anatomy 7-10 days

Decision Evaluate likelihood of spontaneous 10 days-6 weeks

Definitive Treatment
closure
Decide duration of nonoperative
management
Plan operative approach; > 6-12 weeks
Bowel resection, hernia repair,
intestinal diversion, etc.

Healing Continued nutritional support From perioperative period until

Supplementation (vitamins A & C, Zn) fistula resolved

Evenson & Fischer, J Gastrointest Surg 2006;10:455-464a

Enterocutaneous Fistulas: Management Enterocutaneous Fistulas: Management

Recognition & Stabilization:

A.) Fluid & electrolyte repletion
B.) Control of sepsis
C.) Optimize nutrition
D.) Control fistula output
Haider HH, et al. J Am Coll Surg 2008;206(3):592-594
Evenson & Fischer, J Gastrointest Surg 2006;10:455-464

Enterocutaneous Fistulas: Management

Recognition & Stabilization:

A.) Fluid & electrolyte repletion
B.) Control of sepsis
C.) Optimize nutrition
D.) Control fistula output
- somatostatin & octreotide
- negative pressure wound therapy (wound VACs)
 Enterocutaneous Fistulas: Management

Recognition & Stabilization:

A.) Fluid & electrolyte repletion
B.) Control of sepsis
C.) Optimize nutrition
D.) Control fistula output
E.) Local skin care & protection

Evenson & Fischer, J Gastrointest Surg 2006;10:455-464

Enterocutaneous Fistulas: Management

Goal: To restore the continuity and integrity of the gastrointestinal tract.

Phase Goal Time course

Recognition & Stabilization
Investigation
Fluid & electrolyte repletion 24-48 hours
Control of sepsis
Optimize nutrition
Control fistula output
Local skin care & protection
Fistulagram to define anatomy 7-10 days

Decision Evaluate likelihood of spontaneous 10 days-6 weeks

Definitive Treatment
closure
Decide duration of nonoperative
management
Plan operative approach; > 6-12 weeks
Bowel resection, hernia repair,
intestinal diversion, etc.

Healing Continued nutritional support From perioperative period until

Supplementation (vitamins A & C, Zn) fistula resolved

Lloyd DA, et al. Br J Surg 2006;93:1045-55 Evenson & Fischer, J Gastrointest Surg 2006;10:455-464a
 Enterocutaneous Fistulas: Management Enterocutaneous Fistulas: Management

Goal: To restore the continuity and integrity of the gastrointestinal tract.

Investigation:
Phase Goal Time course
A.) Fistulagram Recognition & Stabilization Fluid & electrolyte repletion 24-48 hours
Control of sepsis
- source of the fistula Optimize nutrition
- nature of the fistula tract (e.g., length, course, relationships) Control fistula output
Local skin care & protection
- absence of bowel continuity (end v. side fistula) Investigation Fistulagram to define anatomy 7-10 days

- presence of distal obstruction Decision Evaluate likelihood of spontaneous 10 days-6 weeks

closure
- nature of adjacent bowel (inflammation, stricture) Decide duration of nonoperative
management
- presence of a communicating abscess
Definitive Treatment Plan operative approach; > 6-12 weeks
B.) CT scan Bowel resection, hernia repair,
intestinal diversion, etc.
C.) Intestinal contrast studies Healing Continued nutritional support From perioperative period until
Supplementation (vitamins A & C, Zn) fistula resolved

Evenson & Fischer, J Gastrointest Surg 2006;10:455-464a

Enterocutaneous Fistulas: Management Enterocutaneous Fistulas: Management

Decision:
Decision:
A.) Likelihood of spontaneous closure
B.) Duration of nonoperative managment
- infection
- judgment call
- short fistula tract
- immediate surgery
- high-output fistula
- 4-6 weeks
- side fistula
- >3 months
- malignancy
- malnutrition
- foreign body
- radiation damage
- distal obstruction
- inflammatory bowel disease
 Enterocutaneous Fistulas: Management
Goal: To restore the continuity and integrity of the gastrointestinal tract.
Phase Goal
Recognition & Stabilization Fluid & electrolyte repletion
Control of sepsis
Optimize nutrition
Control fistula output
Local skin care & protection
Investigation Fistulagram to define anatomy
Decision Evaluate likelihood of spontaneous
closure
Decide duration of nonoperative
management
Definitive Treatment Plan operative approach;
Bowel resection, hernia repair,
intestinal diversion, etc.
Healing Continued nutritional support
Supplementation (vitamins A & C, Zn)
Evenson & Fischer, J Gastrointest Surg 2006;10:455-464a
Enterocutaneous Fistulas: Management
Goal: To restore the continuity and integrity of the gastrointestinal tract.
Phase Goal
Recognition & Stabilization Fluid & electrolyte repletion
Control of sepsis
Optimize nutrition
Control fistula output
Local skin care & protection
Investigation Fistulagram to define anatomy
Decision Evaluate likelihood of spontaneous
closure
Decide duration of nonoperative
management
Definitive Treatment Plan operative approach;
Bowel resection, hernia repair,
intestinal diversion, etc.
Healing Continued nutritional support
Supplementation (vitamins A & C, Zn)
Evenson & Fischer, J Gastrointest Surg 2006;10:455-464a
Enterocutaneous Fistulas: Management
Definitive treatment:
Time course
24-48 hours Operative approach, strategies & mind-set
- location of incision
- lysis of adhesions
7-10 days - ensure bowel integrity (ligament of Treitz to rectum)
10 days-6 weeks - bowel resection vs. repair
- intestinal diversion
- abdominal wall closure
> 6-12 weeks
- ventral hernia repair
From perioperative period until
fistula resolved
Enterocutaneous Fistulas: Summary
Complex, highly morbid, life-threatening condition;
Time course
24-48 hours Comprehensive, multi-disciplinary approach;
Early recognition and aggressive patient support;
7-10 days
Eliminate infection & control fistula output;
10 days-6 weeks
Optimize nutrition & opportunity for spontaneous closure;
> 6-12 weeks
Customize the therapeutic strategy.
From perioperative period until
fistula resolved