Management of Enterocutaneous Fistula Dr. Onkar Singh Department of surgery MY Hospital & MGM Medical College, Indore M.P.

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

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

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

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

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

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

CLASSIFICATION Anatomical classification: (1) a. Internal: Two organ of same or different system Enteroenteral, enterovesical,enterocolic, colovesical b. External : Gut to body surface. Gastrocutaneous,duodenocutaneous, enterocutaneous. (2) a. Simple or direct. b. Complicated - 1.Having multiple tracts 2. Connection with more than one viscus 3. drainage into an associated abscess cavity.

Anatomical classification:

(1) a. Internal: Two organ of same or different system

Enteroenteral, enterovesical,enterocolic, colovesical

b. External : Gut to body surface.

Gastrocutaneous,duodenocutaneous, enterocutaneous.

(2) a. Simple or direct.

b. Complicated -

1.Having multiple tracts

2. Connection with more than one viscus

3. drainage into an associated abscess cavity.

Physiological classification High output - output more than 500 ml/ day Moderate output - output 200-500 ml/day Low output - output less than 200ml/day

High output - output more than 500 ml/ day

Moderate output - output 200-500 ml/day

Low output - output less than 200ml/day

Etiologic Classification Radiation Inflammatory bowel disease Diverticular disease Appendicitis Ischaemic bowel disease Duodenal ulcer perforation Malignancies Intestinal tuberculosis Actinomycosis. Spontaneous (15-25%)-

Radiation

Inflammatory bowel disease

Diverticular disease

Appendicitis

Ischaemic bowel disease

Duodenal ulcer perforation

Malignancies

Intestinal tuberculosis

Actinomycosis.

Spontaneous (15-25%)-

2. Post-operative (75-85%) Operations for perforations Acute intestinal obstruction Intestinal malignancies Adhesiolysis Blunt and penetrating abdominal trauma.

Operations for perforations

Acute intestinal obstruction

Intestinal malignancies

Adhesiolysis

Blunt and penetrating abdominal trauma.

3. Congenital Tracheo- esophageal Rectovaginal Umbilical fistula. 4. Traumatic Blunt and penetrating trauma of abdomen, chest and perineum

3. Congenital

Tracheo- esophageal

Rectovaginal

Umbilical fistula.

4. Traumatic

Blunt and penetrating trauma of abdomen, chest and perineum

ETIOLOGY Extension of bowel abnormalities to surrounding structures. Extension of adjacent disease to normal bowel Inadvertent or unrecognized trauma to the bowel. Anastomotic disruption .

Extension of bowel abnormalities to surrounding structures.

Extension of adjacent disease to normal bowel

Inadvertent or unrecognized trauma to the bowel.

Anastomotic disruption .

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.

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.

The operations commonly causing small intestinal fistulas Operation for malignancy, Inflammatory bowel disease Adhesiolysis. The different complications leading to fistula formation include Disruption of an anastomosis, Unrecognized injury to the bowel at the time of lysis of adhesions Inadvertent suture of the bowel at the time of abdominal closures.

The operations commonly causing small intestinal fistulas

Operation for malignancy,

Inflammatory bowel disease

Adhesiolysis.

The different complications leading to fistula formation include

Disruption of an anastomosis,

Unrecognized injury to the bowel at the time of lysis of adhesions

Inadvertent suture of the bowel at the time of abdominal closures.

Fistula may result from anastomosis done in unprepared bowel or in a bowel with less than adequate blood supply. Anastomosis may also be jeopardized by hypotension owing to inadequate resuscitation or by excess tension placed on the suture lines Poor nutritional status contributes to anastomotic breakdown.

Fistula may result from anastomosis done in unprepared bowel or in a bowel with less than adequate blood supply.

Anastomosis may also be jeopardized by hypotension owing to inadequate resuscitation or by excess tension placed on the suture lines

Poor nutritional status contributes to anastomotic breakdown.

Pathophysiology Fluid and electrolyte imbalance. Malnutrition Sepsis Skin irritation and excoriation

Fluid and electrolyte imbalance.

Malnutrition

Sepsis

Skin irritation and excoriation

Natural history Present absent Sepsis Crohn’s, cancer, foreign body, radiation Appendicitis, diverticulitis post operative Etiology malnourished Well nourished Nutritional status Gastric,ileal Esophageal, Duodenal stump, jejunal Anatomic location Unlikely to close Likely to close

Unlikely to close Likely to close <200mg/dl >200mg/dl transferrin epithelization Tract >2 cm Defect < 1cm 2 miscellaneous Total disruption,abscess,total obstruction, active disease. Healthy adjacent tissue, small leak,quiescence disease, no abscess. Condition of bowel

Avg. Time to closure Varies with anatomical location ; Esophageal- 15-25 days Duodenal- 30-40 days Colonic - 30- 40 days Small Bowel- 40-60 days

Varies with anatomical location ;

Esophageal- 15-25 days

Duodenal- 30-40 days

Colonic - 30- 40 days

Small Bowel- 40-60 days

Clinical presentation Recognized 5th-10th days post operatively. Fever Leucocytosis Prolonged ileus Abdominal tenderness Drainage of enteric material through the abdominal wound or through or existing drains.

Recognized 5th-10th days post operatively.

Fever

Leucocytosis

Prolonged ileus

Abdominal tenderness

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 Decreased peripheral vascular resistance

Localized swelling of the abdominal wall.

Point tenderness.

May be

Hypotension

dehydration

Decreased peripheral vascular resistance

Investigations 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

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

Radiological contrast studies Fistulography : A water soluble contrast material is injected into the fistula tract through a 5 or 8 size pediatric tube and it is observed fluoroscopically or through static radiological films. Barium transit studies : Barium meal follow through & barium enemas.

Fistulography : A water soluble contrast material is injected into the fistula tract through a 5 or 8 size pediatric tube and it is observed fluoroscopically or through static radiological films.

Barium transit studies : Barium meal follow through & barium enemas.

FISTULOGRAM

Entero-colic fistula

CT- Scan Entero colic fistula Sigmoid cutaneous fistula Gastro cutaneous fistula

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. CT scan : To evaluate the abdomen for presence of abscess in an aseptic patient.

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.

CT scan : To evaluate the abdomen for presence of abscess in an aseptic patient.

Colonoscopy

Management phases for gastro intestinal fistulas 5-10 days after closure 5. Healing When spontaneous closure is unlikely or after 4-6 wks. 4. Definitive therapy 7-10 days to 4-6 wks. 3. Decision After 7-10 days 2. Investigation Within 24-48 hrs. 1. Stabilization

Stabilization Rehydration Correction of anaemia Drainage of sepsis Electrolyte repletion Osmotic pressure restoration Nutrition support Control of fistula drainage Institution of local skin care

Rehydration

Correction of anaemia

Drainage of sepsis

Electrolyte repletion

Osmotic pressure restoration

Nutrition support

Control of fistula drainage

Institution of local skin care

Stabilization Resuscitation : Restoration of normal circulating blood volume. Correction of electrolyte & acid base imbalance. Plasma oncotic pressure should be restored by exogenous albumin administration.

Resuscitation :

Restoration of normal circulating blood volume.

Correction of electrolyte & acid base imbalance.

Plasma oncotic pressure should be restored by exogenous albumin administration.

Nasogastric tubes : should be removed if There is a no obstruction. Fistula is a low in intestinal tract.

Nasogastric tubes : should be removed if

There is a no obstruction.

Fistula is a low in intestinal tract.

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

Problems in skin around the fistula:

Wetness

Burning pain

Discomfort from skin edema

Goals of skin care:

Containing the effluent

Patient independence and mobility

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

Wound pouch dressings

One/two piece design

Clip closure or Urostomy type

May be attached to a bed side bag or suction catheter

Wound pouch dressing

Skin Barriers: Solid wafers (pectin based) Powders (Pectin / Karaya based) Paste Spray and wipes Ointments and creams (zinc/petroleum based)

Skin Barriers:

Solid wafers (pectin based)

Powders (Pectin / Karaya based)

Paste

Spray and wipes

Ointments and creams (zinc/petroleum based)

Sump Drainage: For fistulae draining with open abdominal wound. Large bore drains or sumps High pressure suction (better results).

Sump Drainage:

For fistulae draining with open abdominal wound.

Large bore drains or sumps

High pressure suction (better results).

Nutritional management: Plays Central role in management Adequate circulation and tissue oxygenation must for optimal utilization. May be: Enteral Parenteral

Nutritional management:

Plays Central role in management

Adequate circulation and tissue oxygenation must for optimal utilization.

May be:

Enteral

Parenteral

Central line

Recommended Nutritional Support 10mg/wk 10mg/wk Vitamin K Close watch Usually not needed Minerals 2RDA Vit C – 5 –10RDA RDA Vit C – 2RDA Vitamins Parenteral (20-30%) Enteral (20-30%) Lipids BEE x 1.5 BEE Calories 1.5-2.5g/kg/day 1-1.5g/kg/day Protein Usually Parenteral Enteral Form High Output Low Output

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.

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.

Patients should receive 3000 to 5000 non proteins calories per day Amino acid 100 to 200 gm. TPN should initiate early in the course of treatment while adynamic ileus persist and before the fistula tract is well established.

Patients should receive 3000 to 5000 non proteins calories per day

Amino acid 100 to 200 gm.

TPN should initiate early in the course of treatment while adynamic ileus persist and before the fistula tract is well established.

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

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

Total Parenteral Nutrition 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 weekly)

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 weekly)

Administration : Central Line: Subclavian Vein Internal Jugular Vein Peripheral line Rate of Infusion: Starting: 50 – 100 ml/hr Gradually increased by 25 – 50 ml/hr every second day

Central Line:

Subclavian Vein

Internal Jugular Vein

Peripheral line

Starting: 50 – 100 ml/hr

Gradually increased by 25 – 50 ml/hr every second day

Patient Monitoring: Clinically: (daily) Sense of well being Graded activity Vitals Weight / input-output Laboratory profile: (daily until patient stable then twice weekly) Serum Electrolytes RFT LFT/ coagulation profile Lipid profile

Clinically: (daily)

Sense of well being

Graded activity

Vitals

Weight / input-output

Laboratory profile: (daily until patient stable then twice weekly)

Serum Electrolytes

RFT

LFT/ coagulation profile

Lipid profile

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%)

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%)

Metabolic Acute Hyperglycemia/hypoglycemia Electrolyte abnormalities Fluid overload Hyperlipidemia Chronic Metabolic bone disease Alterations in bile composition

Metabolic

Acute

Hyperglycemia/hypoglycemia

Electrolyte abnormalities

Fluid overload

Hyperlipidemia

Chronic

Metabolic bone disease

Alterations in bile composition

Enteral Nutrition Benefits: Trophic effect on bowel Stimulates hepatic protein synthesis 4 ft of functional bowel required (proximal or distal) Lipid based formula absorbed more efficiently

Benefits:

Trophic effect on bowel

Stimulates hepatic protein synthesis

4 ft of functional bowel required (proximal or distal)

Lipid based formula absorbed more efficiently

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

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 To be withheld unless the patient is septic Measures to decrease secretions Shortens time to closure ( no role in spontaneous closure) H2 antagonists/ Proton pump inhibitors Somatostatin / octreotide Infliximab (monoclonal antibody) (in Crohn’s disese) Oral tacrolimus (in Crohn’s disese)

To be withheld unless the patient is septic

Shortens time to closure ( no role in

spontaneous closure)

H2 antagonists/ Proton pump inhibitors

Somatostatin / octreotide

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

Oral tacrolimus (in Crohn’s disese)

Emotional support External drainage of enteric contents can be demoralizing Psychiatric evaluation and use of antidepressant drugs Reassurance

External drainage of enteric contents can be demoralizing

Psychiatric evaluation and use of antidepressant drugs

Reassurance

DECISION: No signs of imminent closure after 4- 5 weeks then patient should be prepared for surgery. Unfavorable characteristics since beginning Uncontrolled sepsis urgent drainage of sepsis. If patient general condition very poor then only abscess drainage should be done . In case of malignancies early operation should be done.

No signs of imminent closure after 4- 5 weeks then patient should be prepared for surgery.

Unfavorable characteristics since beginning

Uncontrolled sepsis urgent drainage of sepsis.

If patient general condition very poor then only abscess drainage should be done .

In case of malignancies early operation should be done.

Treatment Patient should be amply resuscitated Drainage cultured Intraluminal and intravenous antibiotic Discontinuation enteral nutrition 1-2 day prior while continuing parenteral nutrition Operative approach preferably through a new incision Best results are with definitive resection and end-to-end anastomosis

Patient should be amply resuscitated

Drainage cultured

Intraluminal and intravenous antibiotic

Discontinuation enteral nutrition 1-2 day prior while continuing parenteral nutrition

Operative approach preferably through a new incision

Best results are with definitive resection and end-to-end anastomosis

Protective diverting stoma proximal to anastomosis Secure closure of abdominal wall over the fistula Post-op nasogastric decompression Feeding jejunostomy ( for proximal fistulae) Post op continuation of nutrition with gradual shift from parenteral to enteral form

Protective diverting stoma proximal to anastomosis

Secure closure of abdominal wall over the fistula

Post-op nasogastric decompression

Feeding jejunostomy ( for proximal fistulae)

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

Operative procedure of fistula

Operated case of enterocutaneous fistula

Late Complications : Short bowel syndrome (after multiple fistula repair) Stricture and partial obstruction at fistula site Esophageal stricture after prolonged nasogastric sump decompression

Short bowel syndrome (after multiple fistula repair)

Stricture and partial obstruction at fistula site

Esophageal stricture after prolonged nasogastric sump decompression

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

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

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

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

Decision making Adequate duodenal mobilization in case of gastroduodenal anastomosis Tube duodenostomy to prevent duodenal stump blow out In multiple typhoid perforations resection of diseased segment and end to end anastomosis is better than primary repair Small bowel defects greater than half the circumference should be treated by resection and anastomosis Proximal diverting stoma should be contemplated in case of gross contamination.

Adequate duodenal mobilization in case of gastroduodenal anastomosis

Tube duodenostomy to prevent duodenal stump blow out

In multiple typhoid perforations resection of diseased segment and end to end anastomosis is better than primary repair

Small bowel defects greater than half the circumference should be treated by resection and anastomosis

Proximal diverting stoma should be contemplated in case of gross contamination.

Stomas with mucus fistula or exteriorization to be considered in medically unfit or aged patients Proper proximal decompression while doing anastomosis .

Stomas with mucus fistula or exteriorization to be considered in medically unfit or aged patients

Proper proximal decompression while doing anastomosis .

HEALING In the postoperative period, it is necessary to ensure that the patient continues to receive full nutritional support. Adequate protein and calories must be provided to maximize healing and minimize complications. Although enteral nutrition may be attempted early in the post-operative course, it is nearly impossible to meet the patient's entire nutritional demand by this route. Postoperative care will most likely include parenteral and enteral supplementation in an overlapping manner.

In the postoperative period, it is necessary to ensure that the patient continues to receive full nutritional support.

Adequate protein and calories must be provided to maximize healing and minimize complications.

Although enteral nutrition may be attempted early in the post-operative course, it is nearly impossible to meet the patient's entire nutritional demand by this route.

Postoperative care will most likely include parenteral and enteral supplementation in an overlapping manner.

After fistula closure, whether by spontaneous or surgical means, the patient will need to resume oral intake. This may be especially difficult in an individual who has had little or no oral intake for 4 to 6 weeks or more, and enlisting the assistance of a dietician and the patient's family is often helpful.

After fistula closure, whether by spontaneous or surgical means, the patient will need to resume oral intake.

This may be especially difficult in an individual who has had little or no oral intake for 4 to 6 weeks or more, and enlisting the assistance of a dietician and the patient's family is often helpful.

THANKS