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MANAGEMENT OF

ENTEROCUTANEOUS
FISTULA

OUTLINE

INTRODUCTION
PHYSIOLOGY
PATHOPHYSIOLOGY
CLINICAL FEATURES
PRINCIPLES OF MANAGEMENT
PROGNOSTIC FACTORS
PREVENTION
COMPLICATIONS
CONCLUSION

INTRODUCTION
A fistula is an abnormal communication
between two epithelial-lined surfaces
Enterocutaneous fistula: btw intestine and
skin
Historical aspects[4]:
Antibiotic era 1945-60
Intensive care 1960-70
TPN era 1970-75

CLASSIFICATION
High & Low - obsolete[4]
Types: NEW CLASSIFICATION Siteges-Sera et al modified by
Schein et al

1. Abdominal oesophagus & gastroduodenal


fistula
2. Small bowel fistula
3. Large bowel fistula
4. Any site with a large abdominal wall defect
(N.B 3. has the best prognosis and 4 has the worst prognosis)

CLASSIFICATION
ANATOMICAL CLASSIFICATION:
CLASSIFICATION
1.

a. Simple or direct.
b. Complicated 1.Having multiple tracts
2. Connection with more than one viscus
3. drainage into an associated abscess cavity.

(2). Circumference of Bowel:

1. LATERAL side of a hollow viscus.


2. END.- whole circumference.

AETIOPATHOLOGICAL
Congenital
Umbilical fistula.

Acquired
TRAUMA
BLUNT
PENETRATING.
POST-OPERATIVE: 80%
ANASTOMOTIC LEAK
UNRECOGNISED BOWEL INJURY.
SURGERIES LIKELY TO LEAD TO THIS:
ADHESIOLYSIS
SUTURE OF PERFORATIONS
ANASTOMOSIS

SPONTANEOUS:
NEOPLASTICMALIGNANCY
INFLAMMATORY:
TB
DIVERTICULAR DISEASE
CROHNS DISEASE
RADIATION ENTEROPATHY
AMOEBIASIS.

PRESSURE: between two epithelial surfaces


gallbladder & duodenum,
stones in biliary ducts- Mirizzi,;
Obstructed ext . Hernias e.g Ritchers.
Umbilical/para

CONTRIBUTING FACTORS

Malnutrition
Sepsis
Hypotension/Shock
Vasopressors
Steroids
Radiotherapy
Anastomotic factors

PHYSIOLOGY
Digestion/ absorption
Water / Electrolyte absorption and
secretion
Carbohydrate digestion/ absorption
Protein digestion/ absorption
Fat digestion / absorption
Vitamin/ mineral absorption
Barrier / immune function
Motility
Endocrine function

PATHOPHYSIOLOGY
Depends on structure involved
Loss of GI Content
Hypovolaemia, Acid-base and electrolyte
abnormalities, Malnutrition.

Sepsis
Intra-abdominal sepsis
Wound infection
Septicaemia

3). Malnutrition
- Reduced oral intake
- Hypercatabolism
- Loss of nutrients
- Loss of digestive juices
- Insufficient absorptive surface

4). Skin irritation & excoriations


5). Anaemia
- Malnutrition
- Sepsis
- Bleeding

Natural history
Likely to
close

Unlikely to close

Anatomic
location

Esophageal,
Duodenal
stump, jejunal

Gastric,ileal

Nutritional
status
Sepsis

Well nourished malnourished


absent

Present

Etiology

Appendicitis,
diverticulitis
post operative

Crohns, cancer,
foreign body,
radiation

Avg. Time to closure

Varies with anatomical location;

1. Esophageal- 15-25 days


2. Duodenal- 30-40 days
3. Colonic - 30- 40 days
4. Small Bowel- 40-60 days

The predominant causes of death are


sepsis, electrolyte imbalance, and
malnutrition.

CLINICAL PRESENTATION
POST OPERATIVE FISTULA
Recognized 5th-10th days Abdominal tenderness
post operatively.
Fever
Leucocytosis
Prolonged ileus

Drainage of enteric
material through the
abdominal wound or
through or existing
drains.

Localized swelling
of the abdominal
wall.
Point tenderness.

May be
Hypotension
dehydration

CLINICAL PRESENTATION
SPONTANEOUS FISTULA:
INDOLENT MANNER.
FEATURES OF UNDERLYING DISEASE.
INTERNAL FISTULA PNEUMATURIA, FAECOLURIA.,
DIARRHOEA, VAGUE ABD PAIN.

FACTORS PREVENTING SPONTANEOUS


CLOSURE

Foreign body in the tract


Radiation-induced fistula
I nfection/Inflammation
Active disease at site of fistula
Abscess cavity

Epithelialization of the tract


Neoplasia -Malignancy
Distal obstruction
Lateral fistula
Bowel wall defect >1cm2
Fistula tract <2cm long
Fistula site: Lat duodenum, proximal to Lig of treitz , ileal

90% of fistulae that will close, do so within


5 weeks of original operation [2][3]
50% of fistulae will close spontaneously [3]
Complex fistulae will undergo
spontaneous closure in 1/3 of cases [2]

PRINCIPLES OF MANAGEMENT
AIM
To restore bowel integrity and continuity

3 Stages of care
Acute
Sub acute
Definitive Repair

Requires multidisciplinary input

Stoma Nurse/Therapist
Dietician
TPN team
Psychologist/Social work

PRINCIPLES OF MANAGEMENT
S Stabilization,Sepsis control, Skin/stoma care
N Nutrition
A Anatomical Assessment/definition
P Planned definitive procedure

Principles of Management
Fluid Resuscitation and Electrolyte
Sepsis Control
Peritonitis/Drainage/Antibiotics/ Wound Care

Skin Care/Stoma management


Gut Management
Nutrition
Oral/enteral/parenteral
Anatomical definition
Understand tract, site
Identify & Mx Contributing/exacerbating
factors
Definitive Repair

Acute Phase: Fluid and Electrolytes


Patients may present malnourished and
dehydrated
Sepsis, and acutely post op
Or several prior surgeries, long course
High fistula output
Dehydrated and hyponatraemic K, Cl,
HCO3

Acute Phase: Sepsis


Commonest cause of death
Source
anastomotic leakage and collections
fistula effluent
central access

External Drainage or acute surgery

Acute Surgery
Acute intervention is necessary in
Generalised peritonitis
Cellulitis/ necrotising fasciitis
Collections not amenable to perc drainage
Complete disruption of an anastomosis
Removal of foreign body e.g. mesh
Feeding gastrostomy/jejunostomy

Acute surgery may have a role in either


excision of fistula or diversion/defunctioning,
if appropriately timed

Acute Phase: Skin care


Skin loss from effluent
Difficult to manage wounds and stomas
Monitoring of fistula output
So
Stoma therapist
Wound care, Vacuum dressing options
Good quality nursing care

Acute Phase: Gut Management


Manipulation of fistula output
Decreased volume means fewer
electrolyte and fluid issues
Possibly contributes to spontaneous
closure
Contributes to skin care

Fistula Output
Replace losses with saline
Rehydrate with electrolytes/glucose
Medication
Antisecretory
PPIs
Somatostatin/Octreotide

Antimotility
Loperamide/lomotil
Codeine

NUTRITION
Malnutrition predicts both mortality and
failure of repair
Multifactorial cause for malnutrition

Chronic illness/ongoing inflammation


Prolonged hospital stay
Loss of nutrients in effluent
High output/short gut

Nutrition Approaches
TPN
Significant contributor to improved mortality
Bowel rest and spontaneous closure
May be only viable option

Enteral
Advantage for SBP, GIT function,
anastomosis
Elemental feeds
Oral, NGT / fistuloclysis / feeding ostomy /
reinfusion

Manage deficiencies
Give adequate calories

ANATOMICAL DEFINITION

Delineate tract
Origin
Path
Length, Width
Define extent of bowel wall disruption
Exclude distal obstruction
Identify Collections
Etiological disease process

CT
Fistulogram
Oral and PR contrast

MRI
Ba enema
Endoscopy

PLAN: Definitive Surgery

OPTIMISE timing (and surgeon)


OPTIMISE nutrition etc
OPTIMISE theatre set up
PLAN strategy
PLAN for other requirements (blood,
stents, other specialties, HDU)

Definitive Surgery: Principles [1][2]


[3][4]
Abdo entry
Via easiest/safest option

Long incision
Upper abdo usu fewer
adhesions
Complete, careful
adhesiolysis
Hydro dissection
technique
Experienced assistant
Repair any serosal tear
or enterotomy as they
occur

Do the easy bit first


Resect fistula and
anastomose bowel if
possible
Consider covering stoma
Interpose omentum
Avoid mesh, settle for a
hernia

SURGICAL TREATMENT
- Preferred op is resection of fistulous segment
and tract with end-to-end anastomosis
- Dissection should be minimal and
preferably sharp[4]
- Omental patch, proximal colostomy or
ileostomy optional

- By-pass or staged operations have no added


advantage
- Duodenal fistulae can be closed by truncal
vagotomy and gastrojejunostomy
- Rectus abdominis Muscle Flap repair in
selected cases

PROGNOSTIC FACTORS
PREDICTORS OF SPONTANEOUS
CLOSURE & MORTALITY
Serum levels of short turnover proteins
A. Albumin
B. Retinol binding pre-albumin
C. Thyroxin binding pre-albumin
D. Serum transferrin

[4]

PROGNOSTIC FACTORS (CONT)


*If they are low the liver cannot synthesize them and
cannot withstand surgery
*Serum transferrin
Predictor of
spontaneous closure
Retinol-binding protein
Thyroxin-binding prealbumin

Predictors of
mortality

REHABILITATION
Continued nutrition support
Zn supplementation
Psychological/ occupational therapy

PREVENTION

[3]

Identification of high risk individuals.


Meticulous surgical technique.

COMPLICATIONS

[3]

Anastomotic stricture
DVT
Adhesive small bowel obstruction
Short bowel syndrome
Recurrence

LITERATURE REVIEW

[3]

23yr retrospective study of 153 cases


treated surgically
Operative repair mortality
30 day 4%
1yr 15%

Morbidity 80%
Success @ 1st attempt 70%
Overall closure rate 84%

CONCLUSION

[4]

Complex, highly morbid, life threatening


condition
Early recognition & aggressive patient
support
Uncomplicated cases will close
spontaneously
Surgery is usually not an immediate priority
except to deal with complications
Comprehensive multi-disciplinary approach

Reference
1. Atlas of Intestinal Stomas 2012
2. Schwartz Principles of Surgery 10 th Ed
2014
3. Maingots Abdominal Operations 11th Ed.
4. Ajao OG, Shehri MY. Enterocutaneous
fistula. Saudi J Gastroenterol [serial
online] 2001 [cited 2011 Jul 22];7:51-4.
Available from:
http://www.saudijgastro.com/text.asp?200
1/7/2/51/33401

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