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1. Dr. Simba Fidel

2.  Introduction
 Classification
 Etiology & Risk Factors
 Clinical Features
 Diagnosis
 Management

3.  A fistula is an abnormal connection between two epithelialized hollow spaces or
organs.
 Enterocutaneous fistula is an abnormal communication between the skin with
various parts of the gut.
 Fistula means “pipe” or “flute” in latin.
 The ileum is the most common site of origin of ECF.

4.  ECF are classified according to source, output volume, and etiology.
 By source: i.e gastro-, duodeno-, jejuno-, ileo-, colo-, recto-
 By output volume;
 Low output; <200ml/day
 Moderate output; 200ml-500ml/day
 High output; >500ml/day
 By Etiology

5.  Webster and Carey proposed 5 general mechanisms for intestinal fistula formation;
1. Congenital: complete failure of the vitellointestinal duct to obliterate, which results in a
ECF to the umbilicus
2. Trauma: enteroatmospheric fistulas after damage control laparotomy
3. Infection: Actinomyces is a common cause of ECF after appendicectomy.
4. Perforation or injury with abscess: Iatrogenic
5. Infammation, Irradiation or tumor

6.  (ECF) are commonly iatrogenic (75-
85%) and are the most common type of
small bowel fistula

7.  Iatrogenic enterocutaneous fistulas usually become clinically evident between the 5th
and 10th postop days.
 Fever,
 leukocytosis,
 prolonged ileus,
 abdominal tenderness, and
 wound infection are the initial signs.
 An enteric fistula can be distinguished from a wound infection by the presence of bile
in the wound.

8.  The diagnosis of an enterocutaneous fistula is clinical.
 Abd CT: the most useful initial test, with enteral contrast
 GI series; eg Enteroclysis, or barium follow-through
 Fistulogram

9.  The treatment of enterocutaneous fistulas should proceed through an orderly
sequence of steps;
i. Stabilization
ii. Sepsis control
iii. Skin care
iv. Nutrition
v. Anatomy identification
vi. Decision and definitive management

10. 1. Stabilization;
 In the first 24hr-48hr
 Aggressive correction of hypovolemia and electrolyte loss should occur early,
 Ongoing fluid losses from moderate-output upper gastrointestinal fistulas should be
replaced with saline and potassium supplementation with serial measurements of serum
electrolytes
 Duodenal or pancreatic fistulas may require bicarbonate replacement to prevent
metabolic acidosis.

11. 2. Sepsis Control;
 Patients who have diffuse peritonitis or evidence of free gastrointestinal perforation on
imaging studies require urgent surgical exploration.
 Diversion of the fecal stream by ostomy is often required and is the preferred approach.
 Hemodynamically stable patients without diffuse peritonitis should undergo abd(CT) to
identify any intra-abdominal source of sepsis; i.e abscess
 Antibiotic management in nonseptic patients with an enterocutaneous fistula is controversial

12. 3. Skin care;
 Wound bags; i.e
ostomy bags
 NPWT

13.  Pharmacological treatment;
 Anticarthatics; eg Loperamide and diphenoxylate-atropine (Lomotil) for diarrhea and high
output fistulas
 Somatostatin analogs; eg Octreotide (SC/IM 50mcg-100mcg q 8-12hrly)
 Antisecretories; eg PPIs and Histamine-2 receptor antagonists
 Cholestyramine — For the uncommon bilioenteric fistula (eg, biliary-
colonic), cholestyramine can be tried.

14. 4. Nutrition;
 73% of enteric fistulae closes spontaneously in adequately nourished patients,
 Nutritional support needs to begin as soon as the patient is stabilized
 Parenteral vs enteral depending on the anatomy of the fistulanutrition via enteral route
helps in maintaining the intestinal mucosal barrier,
 It is advisable to provide at least part of daily nutritional requirement via enteral. (25%)
 In proximal fistula, the enteral feeding tube may be entered beyond the fistula to provide
enteral nutrition

15.  TPN is given in patients who do not tolerate enteral feeds or have longstanding ileus
or before fistulous tract is well established.
 For Low output  caloric req of 30-35kcal/kg/day, & 1-1.5g/kg/d
 High output  45-50kcal/kg/day, & 1.5-2.5g/kg/d of protein intake
 Vitamins, trace elements, zinc and upto 10times the daily requirements of VitC should
be provided
 Mortality rate of 42% with albumin <2.5mg/dl, vs 0% if > 3.5mg/dl
 N.B: for high output NGT, put NPO, and start TPN.

16.  Non-operative fistula closure;
1. Covered enteric stents
2. Endoscopic clipping
3. Fistula plugs
 Fibrin sealant

17.  80-90% will close within 5-6weeks with conservative management
 Surgery done btn 10days and 6wks post-op will encounter the worst adhesions
 Most surgeons would pursue 2 to 3 months of conservative therapy before considering
surgical intervention.
 Specialized centers often delay the definitive surgery for 6 to 12 months
 The patient should by then be nutritionally optimized, should not be septic

18.  Resection of the intestinal segment, fistula tract and the adjacent part of the involved
structure.
 Absence of extensive infection or inflammation=> Primary anastomosis of the divided
intestinal segments and reestablish GI continuity
 In presence of extensive infection the divided intestinal segments are exteriorized
and
 Staged procedure is performed after the infection and inflammation subsides.

19.  Over 60% of intestinal fistulas close spontaneously.
 Operative repair was associated with a 30-day mortality of approximately 4% and
a 1-year mortality of 15%.
 Morbidity was over 80%.
 First attempt at surgical repair was successful in 70% of cases

20.  Acute intra-operative perforations; early identification and closure
 Serosal tears should be repaired
 Aggressive adhesiolysis should be avoided to prevent serosal tears

21.  ECF are abdnormal are abnormal communication btn the gut and skin
 Majority of ECF are due to iatrogenic causes (70-80%). Others include trauma,
congenital and the FRIEND mnemonic
 Diagnosis is clinical. Imagings are adjunct for anatomy identification and ruling out
intra abdominal abscesses
 Drainage of intra abdominal abscess and treatment of sepsis is of utmost importance.
 Most ECF will close spontaneously within 5-6wks, if not a definitive treatment can be
decided on.

22.  Schwarts Principles of Surgery
 Uptodate.com
 COSECSA MCS notes 2021