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MANAGEMENTOF

ENTERO-CUTANEOUS FISTULA

DR. Bikash Bk ThapaMS- General Surgery

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• A Fistula is defined as an abnormal communication between two epithelized surfaces.

• Enterocutaneous fistulas (ECFs) are abnormal communications between the bowel and skin

• Morality rate of 6.5 to 21%.

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HISTORY

• The earliest record of an enterocutaneous Fistula appears in the old Testament Book of judges Written BY Samuel Between 1043 BC and 1004 BC.

• Celsus described the first reported attempt of surgical repair of a colocutaneous fistula.

• In the 18th century John Hunter advocated a conservative approach to fistulas after he noted that fistulas occasionally close spontaneously.

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•In early 1900’s enterostomy was made in healthy bowel proximally in obstructed bowel

•This often would close spontaneously on resolution of obstruction

•This lead to an unrealistic optimistic approach towards all enterocutaneous fistulas

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CLASSIFICATION

Anatomical classification:(1)

Internal: Two organ of same or different system

• Enteroenteral, enterovesical,enterocolic,

External: Gut to body surface.

• Gastrocutaneous,duodenocutaneous, enterocutaneous.

(2)

Simple or direct.

Complicated-

1.Having multiple tracts

2. Connection with more than one viscus

3. drainage into an associated abscess cavity.

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Physiological classification

• High output- output more than 500 ml/ day

• Moderate output- output 200-500 ml/day

• Low output- output less than 200ml/day

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Etiologic Classification

• Radiation

• Inflammatory bowel disease

• Diverticular disease

• Appendicitis

• Ischaemic bowel disease

• Duodenal ulcer perforation

• Malignancies

• Intestinal tuberculosis

• Actinomycosis.

1. Spontaneous(15-25%)-

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2. Post-operative (75-85%)

• Operations for perforations

• Acute intestinal obstruction

• Intestinal malignancies

• Adhesiolysis

• Blunt and penetrating abdominal trauma

• .

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3. Congenital– Tracheo- esophageal– Rectovaginal– Umbilical fistula.

4. Traumatic – Blunt and penetrating trauma of abdomen, chest

and perineum

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ETIOLOGY

• Disease bowel extending to surrounding structures

• Extraintestinal disease involving otherwise normal bowel

• Trauma to normal bowel including inadverent or missed enterotomies

• Anostomotic disruption following surgery for a vareity of conditions

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• Small intestinal fistula are most common type of gastrointestinal fistulas encountered.

• Most series report 70%-90-% of small intestinal fistulas occurs after an operative procedure.

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Factors Influencing

• Malnutriton• Infection• Hypotension• Anemia• Hypothermia• Poor oxygen delivery

• Mobilisation• Handling• Tension• Ischemia• hemostasis

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Nutritional characteristics have been suggested to increase the risk of anastomotic breakdown:

1. Weight loss of 10–15% of total body weight over 3–4 months;

2. Serum albumin less than 3 mg/dL;

3. Serum transferrin less than 220 mg/dL;

4. Anergy to recall antigens; or

5. Inability to perform activities of daily living due to weakness or fatigue.

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PATHOPHYSIOLOGY

• Fluid and electrolyte imbalance.

• Malnutrition

• Sepsis

• Skin irritation and excoriation

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PREDICTIVE FACTORS FOR SPONTANEOUS CLOSUREFACTORS FAVORABLE UNFAVORABLE

ORIGIN Orophyrayngeal, esophageal, duodenal , PB, Jejunal, colonic

Gastric, lateral duodenal, ligment of teritz, ileal

EITOLOGY Postop, appendicitis, diverticulitis Maligancy, IBD

OUTPUT low high

NUTRITION Well nourishedtransferrin > 200 mg/dl

Malnourished< 200 mg/dl

SEPSIS Absebt Present

STATE OF BOWEL Healthy adj tissue, intestinal continuity, absence of obstruction

Ds adj bowel, distal obst, large abscess, bowel discont, prev irradiation

FISTULA Tract > 2 cm, defect < 1cm sq Tract < 1cm, defect > 1cm sq, epithelilisation, FB

MISC Same institution Refered

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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

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MANAGEMENT

THE GOAL are• Re-establishment of bowel continuity• Ability to achieve oral nutrition• Closure of the fistula

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MANAGEMENT PHASES

PHASE TIME COURSE

RECOGNITON / STABILISATION

24 TO 48 HRS

INVESTIGATON 7- 10 DAYS

DECISION 10 DAYS TO 6 WEEKS

DEFINITIVE MANAGEMENT

WHEN CLOSURE UNLIKELY OR 4-6 WKS

HEALING 5 – 10 DAYS AFTER CLOSURE UNTILL FULL ORAL NUTRITON

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Recogniton/stabilisation

• Resuscitation• Control of sepsis• Electrolyte repletion• Provision of nutrition• Control of fistula drainage• Local skin care n protection

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Clinical presentation

• Recognized 5th-10th days post operatively.

• Fever/ shock

• Prolonged ileus

• Erythema of wound

• Abdominal tenderness

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

• leucocystosis

• confirmation can be obtained by oral administration of a nonabsorbable marker, such as charcoal or Congo red

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Resuscitation :

– Restoration of normal circulating blood volume • Hct- 30%

– Correction of electrolyte & acid base imbalance.

– Plasma oncotic pressure should be restored by exogenous albumin administration. - 3 mg/dl

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Control of Sepsis

• Management of local wound infections

• Drainage if Intra-abdominal collections (percutaneous)

• Laparotomy may be required for:– Extensive cellulitis/necrotising fascitis– Incomplete percutaneous drainage of collections– Disruption of anastomosis

• Antibiotics as per indicated

• CVP only after 24 hrs of drainage

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Skin care management:

• Problems in skin around the fistula:– Wetness – Burning pain – Discomfort from skin edema

• Goals of skin care:– Containing the effluent– Patient independence and mobility

T

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Skin Barriers:

– Solid wafers (pectin based)

– Powders (Pectin / Karaya based)

– Paste

– Spray and wipes

– Ointments and creams (zinc/petroleum based)

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Techniques of skin care:

• Wound pouch dressings

– One/two piece design

– Clip closure or Urostomy type

– May be attached to a bed side bag or suction catheter

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Sump Drainage:

– For fistulae draining with open abdominal wound.

– Large bore drains or sumps

– High pressure suction

VAC • Removes chronic edema, leading to increased localized blood flow, and the

applied forces result in the enhanced formation of granulation tissue”

Fistuloscopy with fibrin glue injection Closure within 2-30 days. (Eleftheriadis, 2002)

Dry dressing

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Reduction of fistula output

• Restrict hypo-osmolar fluids• Encourage electrolyte mix• Antisecretory agents– Proton pump inhibitors– Somatostatin or octreotide

• Antimotility agents– Loperamide– Codeine British Journal of Surgery 2006; 93: 1045–1055

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SOMATOSTATIN N ANALOGUE

• Naturally occuring peptide hormone• Inhibitory to gastrointestinal secrection• Plasma half life 1-2 min• Mode– Inhibit gastrin n cholecystokinin– Reduces splanchic blood flow– Reduces rate gastric emptying – Inhibit gall bladder contraction

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Randomized clinical trials of octreotide and somatostatin use

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Reduction of fistula output

•Infliximab (monoclonal antibody) (in Crohn’s disese)

•Oral tacrolimus (in Crohn’s disese)

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• Nasogastric tubes : should be removed if

– There is a no obstruction.

– Fistula is a low in intestinal tract.

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Nutritional management:

– Plays Central role in management

– Adequate circulation and tissue oxygenation must for optimal utilization.

– May be:• Enteral • Parenteral

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•Chapman and colleagues demonstrated that patients receiving optimal nutritional support (3000 calories per day) had a mortality rate of 12% as compared to 55% mortality among patients receiving a sub optimal nutritional regimen.

•Robauk and Nichdoff reported closure of 73% enteric fistulae in patients with adequate caloric supplementation but only 19% healed when nutritional support was inadequate.

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General guidelines• 25–32 kcal/kg/day with a calorie:nitrogen

ratio of 150:1 to 100:1 and at least 1.5 grams per kilogram per day of

• Patients should receive 3000 to 5000 non proteins calories per day

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• Patients daily protein requirement is 1.2 to 2.0 gm kg/day.

• Fluid requirement is 30ml/kg/day.

• Electrolyte requirement/day• Na-70-100 meq/day• K- 70-100 meq/day• Mg- 15-20 meq/day • Ca- 10-20 meq/day

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Low Output High Output

Form Enteral Usually Parenteral

Protein 1-1.5g/kg/day 1.5-2.5g/kg/day

Calories BEE BEE x 1.5

Lipids Enteral (20-30%) Parenteral (20-30%)

Vitamins RDAVit C – 2RDA

2RDAVit C – 5 –10RDA

Minerals Usually not needed

Close watch

Vitamin K 10mg/wk 10mg/wk

Recommended Nutritional Support

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TPN strategy

If BW loss> 20%, TPN initiated gradually to avoid refeeding syndrome

J Clin Gastroenterol 2000; 31(3)

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Harris Benedict Equation

• BEE in kcal per day for men = 66.4 + (13.7 × weight in kg) + (5.0 × height in cm)

– (6.7 × age in years)

• BEE in kcal per day for women = 655 + (9.6 × weight in kg) + (1.8 × height in cm) –

(4.7 × age in years)

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TPN indications

• Inability to obtain enteral access• High output fistulas• GI intolerance with enteral nutrition• Multiple unfavorable factors (ileus, obst, )

• Not proven well in mortality reduction in ECF, but improve spontaneous closure

J Clin Gastroenterol 2000; 31(3)

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TPN• Conc. dextrose: 500ml of 20% Dex. (=400 kcal)

• Fat: 500 ml 10% fat emulsion (=450 kcal)

• Crystalline Amino Acids: 500 ml 10% Amino acids (=8.4 g Nitrogen)

• Daily Vitamin Supplementation ( Vit. K 10 mg/wk)

• Rate of infusion• Starting: 50 – 100 ml/hr• Gradually increased by 25 – 50 ml/hr every second day

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Patient Monitoring:

• Clinically: (daily)– Sense of well being– Graded activity– Vitals– Weight / input-output

• Laboratory profile: (daily until patient stable then twice weekly)– Serum albumin– Serum Electrolytes– RFT– LFT/ coagulation profile– Lipid profile

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Complications of TPN

• Mechanical– Catheter tip malposition (6%)– Arterial laceration (1.4%)– Hydro-pneumo-haemo thorax (1.1%)– Subclavian/Superior vena cava thrombosis (0.3%)– Thrombophlebitis (0.1%)– Catheter embolism (0.1%)

• Septic – Catheter related sepsis (7.4%)

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• Metabolic – Acute• Hyperglycemia/hypoglycemia• Electrolyte abnormalities• Fluid overload• Hyperlipidemia

– Chronic • Metabolic bone disease• Alterations in bile composition

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Enteral Nutritionnasogastic/nasoenteric/fistuloclysis

• Benefits:– Trophic effect on bowel– Stimulates hepatic protein synthesis– Improve immune / hormaonal/ barrier function– Dec infection rate/ metabolic complication– Inexpensive

• 4 ft of functional bowel/ distal patency required

• Lipid based formula absorbed more efficiently

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INVESTIGATION (7-10 days)Objectives of investigation plan: To define-

• Precise anatomical location

• Is the bowel in continuity or is disrupted

• Abscess cavity

• Condition of adjacent bowel

• Is there a distal obstruction

• Etiological disease process

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Radiological contrast studies

• Fistulography :.

• Barium transit studies :

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CT- Scan

Entero colic fistula Sigmoid cutaneous fistula

Gastro cutaneous fistula

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Endoscopic studies• Gastro duodenoscopy : Demonstrates both

underlying disease and presence of fistula.

• Colonoscopy : Fistula is usually not visible but presence of disease and its nature by biopsy can be demonstrated.

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DECISION: (10 days – 6 wks)

Evaluate the likelihood of spontaneous closure Decide duration of trial of nonoperative management

• No signs of imminent closure after 4- 6 weeks then patient should be prepared for surgery.

• Unfavorable characteristics since beginning

• Uncontrolled sepsis urgent drainage of sepsis.

• General condition very poor then only abscess drainage

• In case of malignancies early operation should be done.

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• 90 – 95 % of fistulas that will spontaneously close typically do so within 5 weeks of operation

• Operation during the first 10 days to 6 weeks from diagnosis of postoperative fistulas is made more difficult by the obliterative peritonitis

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Extreme

Great

Moderate

Minimal

Time after Operation

Severity of Adhesions

0 7 14 21 28 42 56 84 6 months

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Window Period

• 7 to 12 days from the most recent laparatomy

• Within this “window period” severity of adhesions are usually milder and repeat laparotomy with the intent of diverting and or repairing the fistula is justified since caring for a well matured stoma is much easier than ECF.

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Why not to operate outside the window period?

• risk of further enterotomy, and fistula formation and devascularization of the small

• If operation occurred outside the window and is difficult ,put tube gastrostomy and “GET OUT”

• Defer any attempt of repeat laparotomy up to 4 preferably to 6 months

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DEFINITIVE MANAGEMENTplan operative approach

• Optimal nutrition parameters• Free of sepsis• Well healed abdominal wall without inflammation• Prophylactic antibiotics • Tapering of tube feeding• Operative approach preferably through a new incision– Transeverse– Midline

• Prevent contamination of abdominal wall tissues

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• Bowel refunctionalisation– Free all adhesion– Drain any abscess– Releive any obstruction

• Disection/ Adhesiolysis – – Start with least dense adhesion– Sharp Dissection– Wet laparotomy pads– Saline injection (hydro dissection)– Extrafascial dissection

• Repair enterotomies – Heineke- Mikulicz

• Repair serosal tears- Lembert sutures ( 5-0 prolene)

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• Best results are with definitive resection and EEA

• > 1/2 circumference be treated by resection and anastomosis

• Direct attack on duodenal fistula is unwise

• Tube duodenostomy to prevent duodenal stump blow out

• Proximal diverting stoma / Tube enterostomy

• Omental flap – to prevent fistulization

• Stomas with mucus fistula or exteriorization

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• Protective diverting stoma proximal to anastomosis

• Secure closure of abdominal wall over the fistula

• Decompression gastrostomy

• Post-op nasogastric decompression

• Feeding jejunostomy ( for proximal fistulae)

• Post op continuation of nutrition with gradual shift from parenteral to enteral form

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HEALING • ensure that the patient receive full nutritional support.

• Adequate protein and calories

• Parenteral and enteral supplementation in an overlapping

• Contibue NG feeding untill 1500 kcal/ day orally

• Oral feeding – 1 week with soft diet

• Zinc supplement

• Cycling tube feedings

• Psychological n emotional support

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Late Complications:

• Short bowel syndrome (after multiple fistula repair)

• Stricture and partial obstruction at fistula site

• Esophageal stricture after prolonged nasogastric sump decompression

• Neuropsychiatric problems

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Prevention of Fistula:

• Prophylactic Antibiotics and Bowel Preparation:

– Polythelene glycol administrtion decreases bacterial load from 10 12-15 to 10 4-5

– Enteral non-absorbable antibiotics reduce it to 10 2-3

– Prophylactic I/v antibiotic at time of induction of anaesthesia with repetition of dose in case of prolonged surgery

– Post op continuation of antibiotic

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• Appropriate hydration to prevent Hypotension and compromised circulation

• Anastomosis in healthy bowel with adequate blood supply; without tension

• Meticulous and precise hemostasis

• Selection of proper needle size,suture

• Omental covering if possible

• Dead space obliterated with live tissue and properly drained

• Drains kept away from anastomosis site

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