Enterocutaneous Fistula

Enterocutaneous Fistula

 An abnormal communication between two epithelialized surfaces

 Anatomic classification names according to organs involved
 High pressure to low
 Aortoenteric, gastrocutaneous, colovesicle
 Physiologic classification based on output
 High-output > 500 cc/day
 Difficulties in fluid management and skin care

 Moderate-output 200-500 cc/day

 Low-output < 200 cc/day
 Usually colonic
Enterocutaneous fistulas Causes

 Post-operative 75-85%

a. Anastomotic disruption

b. Operative trauma (unrecognized)

c. Synthetic mesh

 Others: 15-25%
a. Inflammatory
b. Neoplastic
c. Post-irradiation
d. Post-trauma
FRIEND

 Foreign body
 Radiation
 Inflammation, Infection
 Epithelialization
 Neoplasm
 Distal obstruction
SNAP

 Control of Sepsis and appropriate Skin care

 Nutrition
 Define underlying Anatomy
 Plan to deal with the fistula
Post-operative anastomotic leaks

 INCIDENCE
 Recent series of 1,684 adult patients undergoing large and
small intestinal anastomosis ( Mount Sinai School of
Medicine)
 Jan 2003 to Sept, 2005
 38 patients had anastomotic leak
 Overall leak rate of 2.3 %
Post-Operative Enteric Fistula

Sepsis
 Most frequent cause of death

 Most frequent surgical indication

 Inadequate drainage of infected area

Post-Operative Enteric Fistula
5 Phases of Treatment
 Stabilization
 Investigation
 Decision
 Definitive therapy
 Healing
 Stabilization (2-5 Days)

 Identification
 Resuscitation (crystalloid, colloid, blood)
 Control of sepsis
 Nutritional support
 Control of fistula drainage
Conservative Treatment
Contraindications

 Peritonitis
 Abscess
 Bacteremia
 Bleeding
 Intestinal necrosis
Investigation (7- 10 days)

 Fistulography with water soluble contrast

 Identify source,length,course of the fistula
 Determine the nature of adjacent bowel (inflammation,stricture)
 Evaluate absence or presence of bowel continuity,distal obstruction,abscess
cavity
 Spontaneous closure
 Surgical etiology
 Free distal flow
 Healthy surrounding bowel
 No abscess cavity
 Fistula tract> 2 cm
 Fistula tract not epithelialized
 Defect < 1 cm (no discontinuity)
 Low output (<500 ml/day)
 No co-morbidity
Spontaneous closure
 Good tissue
50%
 Intestinal disease
 Irradiation
14%
 Crohn’s
8%
 Neoplasia
0%
 Age, sepsis, poor nutrition
 Referred from outside institution
Ann Plast Surg. 2006 Dec;57(6):621-5
Conservative Treatment
 Local wound care

 Avoid electrolyte imbalance

 Nutritional support

 Maintain patient morale

Nutrition

 Normal energy expenditure 25 kcal/kg/day

 Hypoalbuminemia is a significant risk factor for mortality
 Mortality rate of 42% with alb <2.5 vs 0% if >3.5
 Nutritional support is mandatory if illness is anticipated to be longer than 10 days
 Good markers are albumin, prealbumin, transferrin, and retinol binding protein
 “If the gut works, use it”
 > 75 cm of distal small bowel is required for absorption
Psychological support

 Great importance !!
 Patient underwent major surgery with complication
 Prolonged hospital stay
 Open wound and fistula effluent has a detrimental effect on body image
 Methods of reducing fistulas output

 Restrict hypo-osmolar fluids

 Encourage electrolyte mix
 Antisecretory agents (PPI,Octreotide)
 Antimotility agents (Loperamide,codeine)
Octreotide

 Trial of Octreotide is worthwhile once patients have been stabilized

 If significant reduction in fistula output within 3 days, octreotide should be continued
Post-Operative Enteric Fistula

Wound Care
 Important role of stomal therapist
 Keep skin dry and clean
 Protection against digestion
 Measurement of output
JH090505
Pacifying the open abdomen with
concomitant intestinal fistula

Layton et al. The American Journal of Surgery (2010) 199, e48–e50

Pacifying the open abdomen with
concomitant intestinal fistula

Layton et al. The American Journal of Surgery (2010) 199, e48–e50

Wound VAC

 Trial of Wound Vac is in order if wound is clean and starts to granulate

 Best if open wound with some depth and no exposed mucosa
Anchor System for Abdominal
Reappoximation
 Predictive factors for spontaneous closure
and/or mortality
Factor Favorable Unfavorable
Organ of origin Esophageal, Duodenal stump, Pancreatic, Gastric, Lateral duodenal,
Biliary, Jejunal, Colonic Ligament of Treitz, Ileal
Etiology Postop (anast leak), Appendicitis, Malignancy, IBD
Diverticulitis
Output Low (<200-500cc/day) High (>500cc/day)
Nutritional status Well nourished, Transferrin >200 Malnourished, Transferrin <200
Sepsis Absent Present
State of bowel Intestinal continuity, absence of Diseased adjacent bowel, Distal
obstruction obstruction, Abscess,
Discontinuity, Irradiation

Fistula characteristics Tract >2 cm, Defect <1cm Tract <1cm, Defect >1cm
Miscellaneous Original operation at same institution Referred from outside institution
 Failure of Conservative Treatment
 Complete separation of anastomosis
 Distal obstruction
 Adjacent abscess
 Diseased bowel
 Epithelialized short tract (<2 cm)
 Large intestinal opening (>1 cm)
 Foreign body
Post-Operative Enteric Fistula

 Timing of operation?
Post-Operative Enteric Fistula
Surgical Treatment

 Emergency: Peritonitis
 Early (<3 weeks)
 Bleeding
 Bowel obstruction
 Intra-abdominal abscess
 Late (>6 weeks)
Obliterative peritonitis

 No man’s land
 Between 10 to 42 days
 95% of spontaneous closure occur within 4-5 weeks
 “Smart” to wait at least 4 months from previous operation
Post-Operative Enteric Fistula
Operative “Tactics”
 Surgeon calm and meticulous
 Decompression of proximal bowel
 2 layers anastomosis
 Continuation of TPN
 Antibiotics
 Closure of abdominal wound
World J Surg 1983 vol.7
JH090505
CONCLUSIONS

 Best outcome result from well-defined management protocol

 Early diagnosis,resuscitation,control of sepsis,nutritional support may limit morbidity abd
mortality
 Avoid risk of major reoperative procedure by an attempt of non-operative management to
allow spontaneous closure
CONCLUSIONS

 If reoperation needed (> 4 months) , plan and execute meticulous resection and
anastomosis
 Simultaneous reconstruction of the abdominal wall by a Plastic surgeon
 Maintain adequate nutrition during the transition back to oral feedings
Thank you