Learning objectives 10.

Make your own algorithm on how to manage this patient,

There is an algorithm in swartz for the management of small bowel obstruction as Figure 28-16 at page 1232, but for this
learning objectives, it was instructed to make our own management for adhesive small bowel obstruction. So for our
algorithm as shown, If there are signs and symptoms of strangulation ( fever, tachycardia or tachynea, localized abdominal
tenderness, leukocytosis) and intestinal ischemia (blood flow to your intestines decreases) then proceed to the operation
room for exploration. If no then, it will be characterized if partial bowel obstruction or complete bowel obstruction. For partial
bowel obstruction. The patient will proceed to NPO, IVF, NGT, Serial abdominal exam. And if the patient develops signs or
symptoms of intestinal ischemia, then proceed to operation room for exploration, and if they are no signs or symptoms of
intestinal ischemia, continue conservative management duration dependent on etiology and surgeon choice. For complete
bowel obstruction, the patient will have NPO, IVF, NGT, and serial abdominal exam, and if the patient develops signs or
symptoms of intestinal ischemia then proceed to operating room for exploration. And if no symptoms of intestinal ischemia,
improving after 24 hours of conservative management, then continue management, and no improvement proceed to
operating room for exploration.

That would be all doc,

So for case 2,

SGD Day 2: CASE 2

A 40-year-old male was admitted in the hospital 20 days post-op after developing a partial small bowel obstruction
secondary to multiple abdominal incisional hernias that required repair; recovery was complicated by the
development of multiple intraabdominal abscesses. His history was significant for a motor vehicle crash dating back
to 2002 where he sustained multiple orthopedic and intra-abdominal injuries that required numerous surgical
interventions. Before transfer to our facility, he underwent lysis of adhesions, repair of multiple hernias and
resection of a loop of small bowel (ileum) with a primary anastomosis after a bowel perforation.

Currently he presented in the ER with a deep wound infection at the inferior pole of the laparotomy site. He has
stable vital signs but show signs of dehydration. Bilious succus fluid was noted to drain from the wound. Daily
wound drainage was estimated to range from 250-330 cc for the past 4 days.

Next slide doc,

For learning objective number 1,

What is ECF? How do we classify ecf?

Next slide doc please,

According to swartzs, A fistula is defined as an abnormal communication between two epithelialized surfaces. The
communication occurs between two parts of the gastrointestinal tract or adjacent organs in an internal fistula or Gi tract with
the skin (An external fistula).

Moreover, Internal fistula- occurs between two parts of the gastrointestinal tract or adjacent organs. And examples of internal
fistulas are enterocolonic fistula or colovesicular fistula. An external fistula involves the skin or another external surface
epithelium. And enterocutaneous fistula or rectovaginal fistula for its examples.

Next slide please,

Types of enterocutaneous fistulas it is based on the volume of output

 ▪ Enterocutaneous fistulas that drain less than 200 mL of fluid per day are known as low-output
fistulas, Low-output fistulas are treated medically. To Lessen passage of fluid → Give TPN,
low-residue diet for colocutaneous fistula and elemental diet for enterocutaneous fistula

((limits dietary fibre to less than 10-15g per day and restricts other foods that
could stimulate bowel activity. The goal of a LRD is to decrease the size and
frequency of bowel movements in order to reduce painful symptoms.))

((The elemental diet is a liquid meal replacement diet that offers a

complete nutritional profile broken down into its most “elemental”
form. Proteins, fats and carbohydrates are broken down into amino
acids, short-chain triglycerides and short-chain maltodextrins,
combined with vitamins, minerals and electrolytes. These dietary
“building blocks” are easily absorbed in the upper digestive tract,
allowing the rest of your digestive system to rest and recover from illness
or injury. They come in a liquid or powder form designed to be mixed
with water. They can be taken orally or enterally (through a tube).))

▪ Moderate output fistula- those that drains between 200 and 500 mL per day

o And high-output fistulas those that drain more than 500 mL of fluid per day. High-output fistulas are
treated surgically unless you can convert it to a low-output fistula. To decrease output give octreotide
or somastostatin.

((MOA Somatostatin and Octreotide- The proposed mechanisms of action include a reduction in splanchnic and
gastroduodenal mucosal blood flow, a decrease in GI motility, inhibition of gastric acid secretion, inhibition of
pepsin secretion, and gastric mucosal cytoprotective effects.)

((A subcutaneous injection is a method of administering medication. Subcutaneous means under the skin. In
this type of injection, a short needle is used to inject a drug into the tissue layer between the skin and the
muscle.))

So for our case, the patient has an estimation of 250-330 cc or mL daily wound drainage for the past 4 days he has
a moderate output fistula.
A fistula is an abnormal communication between two epithelialized surfaces; an
enterocutaneous fistula (ECF), as the name indicates, is an abnormal communication
between the small or large bowel and the skin. An ECF can arise from the duodenum,
jejunum, ileum, colon, or rectum. (See the image below.)

Almost healed wound around an

enterocutaneous fistula.
View Media Gallery
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 this condition. A fistula-in-ano, though anatomically
an ECF, conventionally is not referred to as such, because its presentation and management
are different.
An ECF, which is classified as an external fistula (as opposed to an internal fistula, which is
an abnormal communication between two hollow viscera), is a complication that is usually
seen after surgery on the small or large bowel. In one study, about 95% of ECFs were
postoperative, and the ileum was the most common site of ECF [1] ; 49% of fistulas were
high-output, and 51% were low-output.
ECFs are a common presentation in general surgical wards, and despite advances in the
management of these lesions, they are still responsible for a significant mortality (5-20%),
attributable to associated sepsis, nutritional abnormalities, and electrolyte imbalances.
Understanding the pathophysiology of, as well as the risk factors for, ECFs should help to
reduce their occurrence. Moreover, the well-established treatment guidelines for these
lesions, along with some newer treatment options, should help clinicians achieve better
outcomes in patients with an ECF.
The conventional therapy for an ECF in the initial phase is always conservative.
(See Treatment.) Immediate surgical therapy on presentation is contraindicated; however,
patients who have an ECF with adverse factors may require early surgical intervention.
Treatment of ECFs continues to be a difficult task.
In a landmark article, Edmunds et al provided a comprehensive discussion of ECF. [2] Of 157
patients in the study, 67 developed ECF following surgery. Important complications of ECF
included fluid and electrolyte imbalance, malnutrition, and generalized peritonitis. Mortality
was 62% in patients with gastric and duodenal fistulas, 54% in patients with small-bowel
fistulas, and 16% with colonic fistulas.
Etiology
An ECF can occur as a complication following any type of surgery on the GI tract. Indeed,
more than 75% of all ECFs arise as a postoperative complication, whereas about 15-25%
result from abdominal trauma or occur spontaneously in relation to cancer,
irradiation, inflammatory bowel disease (IBD), or ischemic or infective conditions. The
etiology of ECFs can thus be characterized as postoperative, traumatic, or spontaneous.
Postoperative
Postoperative causes of ECFs include the following:
• Disruption of anastomosis
• Inadvertent enterotomy - Occurs especially in patients with adhesions, when
dissection can cause multiple serosal tears and an occasional full-thickness tear
• Inadvertent small-bowel injury - Occurs during abdominal closure, especially after
ventral hernia repair
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 (eg, diseased or ischemic) bowel, 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.
Gastroduodenal fistulas are seen most often after surgery for perforated peptic ulcer,
especially in developing countries, where perforated peptic ulcer is more common. In
patients with a perforated duodenal ulcer, when the perforation is large, extensive
contamination is present. When the duration between perforation and surgery is long, there
is a high possibility of a postoperative leak, leading to a lateral duodenal fistula. This problem
is difficult to treat, and mortality is high. Other causes of gastroduodenal leakage include
surgery for stomach and the biliary tract cancers.
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]
Hew et al reported a rare case of ECF following migration of a hepatic artery infusion
catheter in a patient with colorectal liver metastasis. [6]
Traumatic
Traumatic ECF results from iatrogenic surgical trauma to the bowel that may or may not be
recognized. Road traffic accidents with injury to the gut can also lead to an ECF. [7]
Spontaneous
Spontaneous causes of ECF, seen in about 15-25% of cases, include the following:
• Malignancy
• Radiation enteritis with perforation
• Intra-abdominal sepsis
• IBD (eg, Crohn disease [3] )
Ulcerative colitis (UC) can also lead to spontaneous ECF, but most cases of ECF associated
with this IBD occur as a postoperative complication of restorative proctocolectomy. [8] Rarely,
inadvertent incision of a malignant tumor can lead to an ECF (see the image below). In this
patient, a urachal tumor was inadvertently incised when the patient underwent an
appendectomy by midline incision. The patient presented with ECF (colocutaneous fistula)
as the urachal tumor that ulcerated on the abdominal wall postoperatively had also infiltrated
the sigmoid colon.

Postoperative malignant enterocutaneous

fistula.
View Media Gallery
A duodenal fistula can occur in association with a perforated duodenal ulcer, but again, it
most often arises postoperatively, resulting from a leak.
Prognosis
ECF is a common condition in most general surgical wards. Mortality has fallen significantly
since the late 1980s, from as high as 40-65% to as low as 5-20%, largely as a result of
advances in intensive care, nutritional support, antimicrobial therapy, wound care, and
operative techniques. [9, 10] Even so, the mortality is still high, in the range of 30-35%, in
patients with high-output ECFs.
Once a patient develops an ECF, the morbidity associated with the surgical procedure or the
primary disease increases, affecting the patient's quality of life, lengthening the hospital stay,
and raising the overall treatment cost. Malnutrition, sepsis, and fluid electrolyte imbalance
are the primary causes of mortality in patients with an ECF.
Another factor that may be a predictor for poor healing outcomes is psoas muscle density,
which can reflect sarcopenia. [11] Assessment of psoas muscle density can identify patients
with ECF who will have poorer outcomes, and these patients may benefit from additional
interventions and recovery time before operative repair.
If sepsis is not controlled, progressive deterioration occurs, and patients succumb to
septicemia. Other sepsis-related complications include intra-abdominal abscess, soft-tissue
infection, and generalized peritonitis. [12]
However, patients with an ECF with favorable factors for spontaneous closure have a good
prognosis and a lower mortality.
Favorable factors for spontaneous closure
Spontaneous closure of an ECF is determined by certain anatomic factors. Fistulas that have
a good chance of healing include the following:
• End fistulas (eg, those arising from leakage through a duodenal stump after Pólya
gastrectomy)
• Jejunal fistulas
• Colonic fistulas
• Continuity-maintained fistulas - These allow the patient to pass stool
• Small-defect fistulas
• Long-tract fistulas
In addition, a fistulous tract of more than 2 cm has a higher possibility of spontaneous
closure. Spontaneous closure is also possible if the bowel-wall disruption is partial and other
factors are favorable. If the disruption is complete, surgical intervention is necessary to
restore intestinal continuity.
Unfavorable factors for spontaneous closure
When an ECF is associated with adverse factors, then spontaneous closure does not
commonly occur, and surgical intervention, despite its associated risks, is frequently
required. In these patients, the outcome is less likely to be good. [13]
Factors preventing the spontaneous closure of an ECF can be remembered by using the
acronym FRIEND, which represents the following [14] :
• Foreign body
• Radiation
• Inflammation/infection/IBD
• Epithelialization of the fistula tract
• Neoplasm
• Distal obstruction - A distal obstruction prevents the spontaneous closure of an
ECF, even in the presence of other favorable factors; if present, surgical
intervention is needed to relieve the obstruction
In addition, lateral duodenal, ligament of Treitz, and ileal fistulas have less tendency to
spontaneously close. [12]
Excoriation
Skin excoriation (see the image below) is one of the complications that can lead to significant
morbidity in patients with ECF. When the enteric contents are more fluid than solid, this
becomes a difficult problem; the skin excoriation makes it difficult to put a collecting bag or
dressings over the fistula, and more leakage leads to an increase in the excoriation.
 Enterocutaneous fistula with severe skin
excoriation.

History and Physical Examination

Features suggestive of an enterocutaneous fistula (ECF) include postoperative abdominal
pain, tenderness, distention, enteric contents from the drain site, and the main abdominal
wound. Tachycardia and pyrexia may also be present, as may signs of localized or diffuse
peritonitis, including guarding, rigidity, and rebound tenderness.
The type of ECF, as based on the output of the enteric contents, also determines the
patient's health status and how the patient may respond to therapy. ECFs are usually
classified into three categories, as follows [3] :
• Low-output fistula (< 200 mL/day),
• Moderate-output fistula (200-500 mL/day)
• High-output fistula (>500 mL/day)
Complications
Patients with ECF present with associated complications, such as sepsis, fluid and
electrolyte abnormalities, and malnutrition.
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 as a consequence of 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. [15]
Sepsis, malnutrition, and electrolyte imbalance are the predominant factors that lead to
death in patients with ECF. [16] Rarely, intestinal failure can occur as one of the complications
of ECF, which results in significant morbidity and mortality. [17]
A high-output fistula increases the possibility of fluid and electrolyte imbalance and
malnutrition.

Laboratory Studies
The following laboratory studies are performed in the evaluation of an enterocutaneous
fistula (ECF):
 • Total white blood cell (WBC) 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 (CRP) - Levels may be elevated
Imaging Studies
Fistulography
During fistulography (see the images below), a water-soluble contrast agent is injected into
the fistulous tract.

Fistulogram showing enterocutaneous fistula.

View Media Gallery
 Fistulogram showing a colocutaneous fistula
following anastomotic leak after colostomy closure.
View Media Gallery
Fistulography is conventionally performed 7-10 days after the presentation of an ECF and
provides the following information:
• Length of the tract
• Extent of the bowel-wall disruption
• Location of the fistula
• Presence of a distal obstruction

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 [18] :
• 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-o’clock to 2-o’clock position)
• Posterior - Dorsal (4-o’clock to 8-o’clock position)
• Lateral - Right (2-o’clock to 4-o’clock position) or left (8-o’clock to 10-o’clock
position)
Additional tract features seen with a WCE include a cavity (pooling of contrast within space),
a stricture (narrowing of anastomosis, with hold of contrast), or both. The presence of a
stricture and a large cavity on WCE predicts failure of healing.
Computed tomography
Computed tomography (CT) is useful for demonstrating intra-abdominal abscess cavities.
Such cavities can develop 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 intra-abdominal
sepsis, then interloop abscesses may be present.
Ultrasonography
A comprehensive ultrasound examination has been employed for the evaluation of
postoperative complications after hernia repair. Whereas point-of-care ultrasound (POCUS)
has been commonly used for abscess evaluation, it can also be an alternative in an
emergency presentation of an ECF. [19]
Other Tests
Oral administration of a nonabsorbable marker (eg, charcoal or 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.

Approach Considerations
The conventional therapy for an enterocutaneous fistula (ECF) in the initial phase is always
conservative. Immediate surgical therapy on presentation is contraindicated, because the
majority of ECFs spontaneously close as a result of conservative therapy. Surgical
intervention in the presence of sepsis and poor general condition would be hazardous for the
patient.
However, patients who have an ECF with adverse factors, such as a lateral duodenal fistula,
an ileal fistula, a high-output fistula, or a fistula associated with a diseased bowel, may
require early surgical intervention.
Zhou et al described a novel technique of using the orchid Bletilla striata in the closure of
ECF. [20] In a case of ECF following colonic neoplasm resection managed conservatively,
application of B striata led to spontaneous closure of the fistula. This plant was found to
suppress inflammation and promote wound healing.
Conservative Therapy
Conservative treatment should usually be administered for a period ranging from a few
weeks to a few months. The principles of nonsurgical therapy for ECFs include the following:
• Rehydration
• Administration of antibiotics
• Correction of anemia
• Electrolyte repletion
• Drainage of obvious abscess
• Nutritional support
• Control of fistula drainage
• Skin protection
With the above-mentioned supportive therapy, spontaneous closure occurs in almost 70% of
patients. In a study of 186 patients, Reber et al found that 91% of small-bowel fistulas that
closed spontaneously did so within 1 month after sepsis was cured. The remaining fistulas
that closed spontaneously did so by the end of 3 months after sepsis cure, with the rest of
the lesions requiring surgical closure. [21]
Uba et al reported that the majority of ECFs in children closed spontaneously following high-
protein and high-carbohydrate nutrition. [22] They found that hypoalbuminemia and jejunal
location were important variables resulting in nonspontaneous closure, whereas
hypokalemia, sepsis, and hypoproteinemia/hypoalbuminemia were risk factors for high
mortality in children with ECF.
Rehydration, electrolyte repletion, and nutritional support
Common fluid and electrolyte problems that must be corrected in patients with an ECF
include the following:
• Dehydration
• Hyponatremia
• Hypokalemia
• Metabolic acidosis
The author uses parenteral nutrition more often in patients with a proximal small-bowel ECF,
especially if it is in the proximal jejunum, or with a high-output fistula. In patients with a distal
ECF, the author prefers to use enteral nutrition whenever possible.
Studies have shown that the provision of only 20% of calories fed enterally may protect the
integrity of the mucosal barrier, as well as the immunologic and hormonal function of the
gut. [12] Hence, a combination of parenteral and enteral nutrition can be used. In high-output
fistulas, the author uses this combination therapy.
In patients with a proximal fistula, if a nasojejunal tube can be introduced beyond the site of
the fistula, then these patients can be supported with enteral nutrition, provided that there is
at least 4-5 ft (1.2-1.5 m) of small bowel distal to it and no distal obstruction. Patients with
chronic small-bowel ECFs may need additional supplementation with copper, folic acid, and
vitamin B12. [12]
Total parenteral nutrition
Total parenteral nutrition (TPN) is usually indicated with suspected gastric, duodenal, or
small-bowel fistula. When the fistula output is very high, discontinuance of oral intake is
recommended because oral intake stimulates further losses of fluids, electrolytes, and
protein via the fistula. A decrease in fistula output frequently occurs with the initiation of TPN.
Home parenteral nutrition (HPN) is a vital therapy for patients who have the diagnosis of
ECF, and it has reported to be successful for patients with ECF as compared with other HPN
patients. [23] Greater provision of protein, more frequent NPO (nil per os) status, and a goal of
future surgery should be the focus in ECF patients on HPN.
Water requirements for TPN are 1 mL/kcal/day. Electrolyte requirements for TPN are as
follows:
• Sodium (Na) - 80-100 mEq/day
• Potassium (K) - 75-100 mEq/day
• Magnesium (Mg) - 15-20 mEq/day
• Calcium (Ca) - 15-20 mEq/day
Calorie and protein requirements are as follows:
• Maintenance – 25-30 kcal, 1.0-1.2 g/kg/day
• Moderate stress – 30-40 kcal, 1.3-1.4 g/kg/day
• Severe stress – 40-45 kcal, 1.5-2.0 g/kg/day
Protein (g)/6.25 should equal nitrogen (g), and the nonprotein calorie-to-nitrogen ratio should
be as follows:
• Maintenance - 200-300:1
 • Moderate stress - 150:1
• Severe stress - < 100:1
A standard, general-purpose formula for TPN consists of the following:
• Glucose, 75 g
• Amino acids, 20 g
• Lipids, 30 g/L
The introduction of ethyl vinyl acetate bags has made the admixture of fat emulsion with
dextrose and amino acids possible (three-in-one concept). [24] This leads to a more uniform
administration of a balanced solution containing the three macronutrients plus micronutrients
over a 24-hour period.
Enteral nutrition
Enteral nutrition is the mainstay of treatment for patients with ECFs. In fistulas of the distal
ileum, colon, or duodenum, enteral nutrition should be considered and can be administered
via various routes. Conventionally, when a gastroduodenal anastomosis or closure is needed
in adverse conditions, a concomitant feeding jejunostomy is performed, so that access is
available for enteral nutritional support in case of an anastomotic leak.
The other routes of administration can be via nasogastric/jejunal tubes or a gastrostomy.
High rates of feeding should be avoided to prevent hyperosmolar diarrhea. Elemental diets,
that is, nonresidue balanced diets with protein components reduced to their basic elements,
are preferred. When a tube enterostomy is performed, proper fixation is necessary to prevent
complications, such as dislodgment of the tube or antegrade migration in the gastrointestinal
(GI) tract. [25]
Martinez et al reported a prospective randomized trial on the effect of preoperative
administration of oral arginine and glutamine in 40 patients with ECF undergoing definitive
surgery, of whom 20 received standard medical care (control group) and 20 received enteral
supplementation with arginine 4.5 g/day and glutamine 10 g/day for 7 days prior to surgery
(test group). [26] The primary outcome was recurrence; secondary outcomes were pre- and
postoperative serum interleukin (IL)-6 and C-reactive protein (CRP) levels and infectious
complications. The recurrence rate was 10% in the test group and 45% in the control group.
The test group had lower IL-6 and CRP levels and no infectious complications.
Fistuloclysis
Enteral nutrition can also be administered in patients with high-output proximal
jejunocutaneous or ileocutaneous fistulas with good mucocutaneous continuity. Feeding can
be administered through a feeding tube inserted in the distal limb of the ECF. Teubner et al
and Ham et al reported good results with this method in select patients to improve the
nutrition of the patient, which is helpful for subsequent fistula closure and promotes healing
of the fistula. [27, 28, 29] An interprofessional approach is needed. [30]
Skin management
Irrgang et al developed a fistula assessment guide that has aided skin management related
to ECFs. [31] This guide is based on the following characteristics:
• Origin of fistula
• Nature of effluent
• Condition of skin
• Location of fistula opening
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.
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.
Pouches used for skin care
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.

Wound manager.
View Media Gallery
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 low-output
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.

View Media Gallery

Zinc oxide cream barrier around

enterocutaneous fistula, with the fistula opening seen.
View Media Gallery
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. [32]
 Intubation of fistulous tract with drain.
View Media Gallery
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. [33] (Octreotide
use is associated with an increased incidence of cholelithiasis. [12] ) Two meta-analyses
showed that somatostatin and its analogues decreased the time for fistula closure and
increased the closure rate. [34, 35] However, there was no significant change in the mortality
with the use of somatostatin or its analogues.
A study on management of high-output ECF with continuous triple-cavity tube drainage in
combination with sequential somatostatin-somatotropin administration was reported in three
patients with three different forms of ECF (duodenal, jejunal and ileal) and three different
approaches to drainage tube (through the initial drainage channel, puncture with dilatation,
and tract reconstruction, respectively). [36] This measure was carried out with the aims of
creating a stable controlled fistulous tract and promoting its healing. It was found to be safe
and effective, especially when surgery was contraindicated.
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. [37]
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. [33] Administration of agents that decrease intestinal pressure may
enhance the efficacy of VAC. [38]
Oliva et al described a nonoperative technique involving the insertion of an occlusive device
to redirect the intestinal content to the distal bowel in patients with lateral high-output
ECF. [39] This was a transient procedure aimed at reducing the fistula output.
Electrical nerve stimulation
Electrical nerve stimulation (ENS) increases blood flow in ischemic tissues and encourages
healing. Berna et al reported the successful use of ENS in two patients with a low-output
ECF. In the study, the direction and depth of the fistula tract were ultrasonographically
determined. A sterile compress impregnated with saline solution was then introduced
through the fistula. The positive electrode was positioned on the compress, and the negative
electrode was positioned over the fistula orifice. [40]
The treatment was given once daily for 1 hour, with one patient requiring 10 treatment
sessions to heal and the second patient requiring 20 sessions. ENS was well tolerated by
both patients, and no complications were noted. No recurrence of the fistula developed over
a 3-year follow-up period.
Laser ablation for chronic ECF after failed conservative therapy
Laser ablation has been used for the treatment of chronic ECFs after failure of conservative
therapy. In a study by Srinivasa et al, three patients underwent laser ablation for treatment of
eight ECFs (mean duration of ECF, 28 months; mean fistula output, 134 mL/day). [41] Initially,
all of the ECFs responsed completely to laser ablation, with no major or minor complications;
however, later three ECFs subsequently required repeat treatment. Overall, at a mean
follow-up of 53 days, seven fistulas healed, and one showed a markedly reduced output (10
mL/day).
Andrés Moreno et al reported the successful use of combination therapy with a laser diode
followed by embolization of the tract with platinum coils and cyanoacrylate to close an ECF
after multiple surgical procedures. [42]
Surgical Therapy
Indications for surgery
Patients who an ECF with adverse factors may require earlier surgical intervention. These
adverse factors include the following:
• Lateral duodenal or ligament of Treitz fistula
• Ileal fistula
• High-output fistula
• Fistula associated with diseased bowel, distal obstruction, or eversion of mucosa
(see the image below)
 Eversion of mucosa in an enterocutaneous
fistula, an unfavorable condition for spontaneous closure.
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Enteroatmospheric fistula (EAF), a special subset of ECF, is defined as a communication
between the GI tract and the atmosphere. [43] It can occur as a complication of "damage
control" laparotomy (DCL) and results in significant morbidity and mortality. The etiology is
complex and ranges from persistent abdominal infection, anastomotic dehiscence, and
adhesions of the bowel to fascia with a laparostoma. Multiple fistulas and preoperative CRP
levels higher than 0.5 mg/dL have been reported to be associated with recurrence after
closure of EAF. [44]
Because EAFs almost never close spontaneously, definitive repair usually requires major
surgical intervention. Complex abdominal-wall reconstruction immediately after fistula
resection is necessary for all EAFs once the infection has subsided, which may be 6-12
months after the original insult. [45] A “fistula patch” technique has also been reported for
protecting open abdominal wounds from being contaminated by intestinal fistulae drainage,
while and simultaneously applying enteral nutrition. [46]
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.
In patients with no associated adverse factors, the author usually waits for about 3-4 months
before planning surgical therapy for an ECF.
Surgical therapy [47] should be undertaken in patients with conventional fistulas without any
adverse factors if the patient is stable, has no sources of sepsis, and can withstand the
resectional procedure needed for fistula closure. [12] It is also important that it be technically
feasible to perform the procedure without posing a very high risk of injury to the bowel or
other important structures. 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.
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Fistula tract being excised.

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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. [12]
Incision
When performing surgery for an ECF, the author makes a point of always entering the
abdomen through a fresh incision, given the possibility that the gut may be 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 this approach for small-bowel 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. [10] 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. [12] 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. [48] 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. [49]
Postoperative Care
In the postoperative phase of surgical therapy for an ECF, good nutritional status is essential
because healing of the tissue and anastomosis depends on it.
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 follow-up to
prevent disease recurrence or recurrence of the ECF. [50] 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.
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. [51] Once a fistula had been endoscopically located, 2-4 mL of
reconstituted fibrin glue (Tissucol 2.0 at 37°C) was injected through a catheter. The patients
required a mean of 2.5 treatment sessions (range, 1-5), and the mean healing time was 16
days (range, 5-40). After treatment, 87.5% of the low-output fistulas and 55% of the high-
output fistulas sealed completely. No complications occurred.
Issak et al reported a case in which concurrent over-the-scope-closure (OTSC) stent
placement was successfully used in a patient who had a perforated duodenal ulcer with
chronic recurrent ECF. [52] Under fluoroscopic guidance, a fully covered metal stent was
placed into the duodenum.
Truong et al described the use of a polyglactin plug in combination with fibrin glue in the
treatment of ECFs. [53] 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. [33]
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. [54]
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. [55]
Extracellular matrix enterocutaneous fistula plugs (ECMFPs) are an alternative in patients
with low-flow ECFs, especially when they are not candidates for a surgical procedure. In a
study assessing the use of ECMFPs in 18 patients with enteric fistulas, Smith et al reported
that fistula closure was achieved in 25% of gastrocutaneous fistulas, 44% of
enterocutaneous fistulas, and 50% of colocutaneous fistulas. [56] The median time of fistula
closure was 25-29 days. Recurrence after closure and failure of closure were more common
in patients with high-flow fistulas.
Gelfoam embolization
Lisle et al described successful treatment of three cases of ECF with embolization of
Gelfoam at the enteric opening of the fistula. [57] In this technique, the ECF was assessed by
means of computed tomography (CT) and fistulography to rule out any intra-abdominal
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. [57]