kathmandu medical college, department of surgery

1. Enterocutaneous fistula(ECF)
Management…
Uttam Laudari
1st year Resident
General surgery
KMCTH

2. Objectives:
• Identification and stabilization of ECF
• Nutrition supplementation and various routes
• Role of fistulogram and other imaging modalities in ECF
• Timings for operative interventions and trial of nonoperative
intervention

3. Management goals
‘‘SNAP’’
• Management of Sepsis and Skin care
• Nutritional support
• Definition of intestinal Anatomy
• Development of a surgical Procedure to deal with the fistula
Management of Enterocutaneous Fistulas Manish Kaushal, F.R.C.S.and Gordon L. Carlson, B.Sc., M.D., F.R.C.S.

6. Recognition and Stabilization
• Identification and Resuscitation
First few days they may do well
– Within a week
• Erythema of wound
• Purulent drainage
• Enteric contents
suffer delayed return of
bowel function and fever

7. • The diagnosis is now clear and management shifts from
routine postoperative care to the management of a potentially
critically ill patient.

8. First stage in management
Crystalloid
and colloid
Blood
products
Albumin
Restore
oxygen
carrying
capacity and
plasma oncotic
pressure
Support
O2
carrying
capacity.
HCT >= 30
Wound healing
Intestinal
function
( 3g/dl)

9. First stage in management…….
• Oral intake stopped and bowel put to rest
• NG tube only if obstructive features are present
• Accurate measurement of output from all orifices
An ECF in the proximal jejunum fluid loss >6 L of per day
loss of the normal inhibitory effect on gastric secretion
gastric hypersecretory state coexists with the intestinal fistula, compounding
management

10. Control of sepsis
• Frankly septic patients should be explored to drain abscesses
• Percutaneous drainage of collections in nonseptic patients
should also be performed
• Pigtail catheter followed by fistulogram by injecting water-
soluble contrast into the abscess under fluoroscopic guidance
• Antibiotics for specific indications

11. Control of fistula drainage and skin
care
• prevents continued irritation of the surrounding skin and
abdominal wall structures
• low-output fistulas may appear to be adequately managed with
dry dressings
• a sump constructed from a soft latex catheter (i.e., Robinson
nephrostomy tube) may be placed in the wound.

12. soft at body temperature and will not erode into the bowel or abdominal wall structures

13. Control of fistula drainage and skin
care……
• Through a number of preparations including Karaya powder,
ileostomy cement, Stomahesive, or ion exchange resins.
• Vacuum-assisted closure (VAC) devices have 46%- 84% non
operative closure rate
• Disadvantage of VAC dressings is time consuming to change
these dressings.
• However, these dressings need only be changed every 5 or so
days.

15. VAC
Negative pressure assists with
– removal of interstitial fluid
– decreasing localized edema
– increasing blood flow
– Additionally, mechanical deformation of cells is thought to
result in protein and matrix molecule synthesis, which
increases the rate of cell proliferation.
An introduction to the use of vacuum assisted closure Steve Thomas PhDDirector
Surgical Materials Testing LaboratoryBridgend, Wales, UKPublished: May 2001
decreases tissue
bacterial levels

16. 46%- 84% non operative closure rate

17. Reduction in Fistula output
• may facilitate wound management and decrease the time to closure.
• histamine antagonists or proton pump inhibitors
– prevention of gastric and duodenal ulceration as well as decrease the
stimulation of pancreatic secretion.
• Sucralfate reduce gastric acidity,
constipating action that may decrease fistula output as well
• High doses of anti motility drugs such as loperamide (up to 36 mg daily)
and codeine phosphate (up to 240 mg daily) are also used to decrease
fistula output
(Surgical Management of Enterocutaneous Fistula Suk-Hwan Lee, MD, PhD, Korean J Radiol.
2012 Jan-Feb; 13(Suppl 1): S17–S20 Published online Apr 23, 2012.)

18. Somatostatin and octreotide
inhibitors of the secretion of
gastrin, cholecystokinin,
secretin, insulin, glucagons,
and vasoactive peptide
Reduce gastrointestinal
secretions, fistula output, and
time to closure
Data that demonstrate an effect on the rate of nonoperative closure of enterocutaneous
fistulas are lacking.
Torres AJ, Landa JI, Moren-Azcoita M et al. Somatostatin in the management of gastrointestinal fistulas: a
multicenter trial. Arch Surg 1992;127:97 [PubMed: 1346491]
However,
Octreotide may accelerate closure of pancreatic fistulas
Cellular apoptosis, Villous atrophy, Interruption of intestinal adaptation, acute cholecystitis
Side Effects

19. Nutritional Support
• Malnutrition, identified by Edmunds in 1960 as a major
contributor to mortality in these patients, may be present in
55–90% of patients with enterocutaneous fistulas.
Edmunds LH, Williams GM, Welch CE. External fistulas arising from the gastro-intestinal tract.
Ann Surg 1960;152:445 [PubMed: 13725742]
• Proper nutrition may
– improve immune function
– provide protein precursors for wound healing,
– and support the functions of the gastrointestinal tract.
1. Poor enteral intake
2. Hypercatabolic septic
state
3. Loss of protein rich
enteral content

20. Plan for Nutritional Supplementation
• Assessment of the patient's nutritional status using elements of history via the
– Subjective Global Assessment
– laboratory values,
– anthropometric analysis,
– bioelectrical impedance anaylsisprovide a baseline and starting point for
planning.
– Harris-Benedict equations and appropriate stress factors.
– (indirect calorimetry) can provide ongoing assessment of the appropriateness of
macronutrient balance
• General guideline,
– 25–32 kilocalories per kilogram per day
– a calorie:nitrogen ratio of 150:1 to 100:1
– at least 1.5 grams per kilogram per day of protein

21. Oxford text book of Surgery 2nd Edition. Chapter 24.3 Gordon Carlson and
Miles Irving
• Fistula losses may be very dramatic when the fistula arises
from the proximal small intestine.
• Losses from a lateral duodenal fistula, for example, may
exceed 6 liters each day.
• daily fistula losses from the small intestine > 500 ml should
be replaced with NORMAL SALINE with 20 mmol per litre
of potassium chloride.

22. Oxford text book of Surgery 2nd Edition. Chapter 24.3 Gordon Carlson and
Miles Irving
proximal small intestinal fistulasTPN is almost always
required
except
occasionally, when access to the small intestine distal to
the site of the fistula can be obtained.
In such cases, the distal intestine can be intubated and
enteral feeding initiated provided that radiological studies
have confirmed the remaining bowel to be intact.

23. • Parenteral nutrition  once sepsis has been controlled and
appropriate intravenous access has been established.
• Transition to partial or total enteral nutrition has been
advocated in recent reports
– to prevent atrophy of gastrointestinal mucosa
– support the immunologic and hormonal functions of the gut and liver

24. • Parenteral nutrition
– expensive
– requires dedicated nursing care
– undue morbidity and mortality from line insertion,catheter sepsis, and
metabolic complications.
Thus, attempting enteral feeding is appropriate in most
fistula patients.
• As achieving goal rates of enteral feeding may take several days,
patients are often maintained on parenteral nutrition as tube feedings
are advanced

25. • Enteral feeding may occur
– per oral
– via feeding tubes placed nasogastrically or nasoenterically,
– via the fistula itself (i.e. fistuloclysis).
• Enteral support typically requires 4 feet of small intestine
and is contraindicated
in the presence of distal obstruction.

26. Drainage from the fistula may be expected to increase with the
commencement of enteral feeding
however,
spontaneous closure may still occur, often preceded by a
decrease in fistula output

27. Teubner A, Morrison K, Ravishankar HR et al. Fistuloclysis can successfully replace parenteral
feeding in the nutritional support of patients with enterocutaneous fistula. Br J Surg 2004;91:625
[PubMed: 15122616]
• used fistuloclysis in 12 patients prior to reconstructive surgery.
• Gastrostomy tubes were placed into the bowel distal to the fistula and iso-
osmotic polymeric tube feedings were commenced without reinfusion of
chyme from the proximal fistula.
11/12 patients were able to discontinue parenteral support
and
9/12 nutritional status was maintained until surgery in (19–422 days)
and
for at least 9 months in the 2 patients who did not undergo operative
intervention.
this study also reported improved bowel caliber, thickness, and ability to hold
sutures in patients who had received enteral nutrition.

28. Phase 2- Investigations:
• This typically occurs 7–10 days after the identification of the fistula and
allows time for the fistula tract to mature to the point where catheters can
be placed in all orifices.
• Careful fistulography with water-soluble contrast provides information not
obtainable through any other means
length, course, and relationships of the fistula tract,
the absence or presence of bowel continuity or distal obstruction,
the nature of the bowel adjacent to the fistula,
 the absence or presence of an abscess cavity in communication
with the fistula

29. • Contrast enema-
– colocutaneous fistula (90%), colovesical fistula (34%), coloenteric
fistula in most cases
• Cystoscopy-
– 40% in enterovesical fistula
– Localized bullous edema, erythema, ulceration
• Endoscopy or colonoscopy-
– to determine the origin of bowel disease that caused fistula ( not to
reveal fistula)
– biopsy in cases of IBD, Crohns,malignancies
• Dye injection- methylene blue rectovaginal fistula

30. • Ultrasonography-
– identifies, abscesses and fluid collection along the fistulous
tract
• Barium enema and small bowel series-
– evaluates stomach, SI and colon
– reveals fistula and identifies cause ( diverticular diseases, Crohn’s,
malignancy)
• Role of CT- scan
– Evaluation for resolution of intra abdominal abscess and presence of
intrinsic intestinal disease
– Leakage of contrast medium from lumen
– Intra abdominal abscess can be sought and drained percutaneously
– Reveals perifistular inflammation
– CT angiography- suspected aortoenteric fistula

31. • Role of MRI
– Identifies and characterize enteric fistulas
– Artifacts may limit its usefulness
– Not considered a routine adjunctive study
T1 weighted images T2 weighted images
provides information relative to the
inflammation in fat planes and
possible extension of the fistula
relative to the surrounding visceral
structure
demonstrate fluid collection along
the fistula tract and inflammatory
changes with in the surrounding
muscle

32. Phase 3-Descision
• Ideally, provision of a period of sepsis-free nutrition will result
in closure of enterocutaneous fistulas within 4–6 weeks.
• Spontaneous closure of fistulas restores intestinal continuity
and allows resumption of oral nutrition.
• Unfortunately, complex fistulas undergo spontaneous closure
in only one-third of cases.
• Therefore, once recognition and stabilization is done
a decision must be made regarding the likelihood of spontaneous
closure of a specific fistula.

33. Phase 3……
Anatomic
Details
Prognostic
details
clinical course of the patient
•weight gain,
•improvement in nutritional
parameters,
• decrease in fistula output
Imaging
Investigations

34. Imaging investigations
lower rates of spontaneous
closure
fistulas originating in
• the stomach
• ileum
• near the ligament of Treitz
unlikely to close without
operative intervention
fistulas arising
• diseased bowel
•in proximity to large
abscesses
•in settings of disruption of
intestinal continuity
•in the presence of distal
obstruction,
• and those with short tracts
(less than 2 cm)
more likely to resolve
spontaneously
fistulas arising from
•biliary
• pancreatic
•or jejunal sources

35. • The timing of operative intervention for fistulas that are
unlikely to or fail to close is important
• Early operation is indicated to control sepsis not amenable to
percutaneous intervention.
• These early procedures are typically limited to drainage of
abscesses and resection of phlegmona.

36. • The common practice of waiting at least 4–6 weeks for
definitive operative management of enterocutaneous fistulas is
based on several factors.
• First, 90–95% of fistulas that will spontaneous close typically
do so within 5 weeks of the original operation.
• Furthermore, operation during the first 10 days to 6 weeks
from diagnosis of postoperative fistulas
more difficult due to "obliterative peritonitis"
described by Fazio and associates.

37. Fazio VW, Coutsoftides T, Steiger E. Factors influencing the outcome of
treatment of small bowel cutaneous fistula. World J Surg 1983;7:481
[PubMed: 6624123
reoperations within 10 days
of or delayed at least 6 weeks
from the original procedure
resulted in mortality rates of
13% and 11%, respectively.
patients undergoing
reoperations between
10 days and 6 weeks of
the original laparotomy
suffered a mortality
rate of 26%
delaying operative intervention allows
•for nutritional support
•normalization of serum albumin and transferrin
•resolution of local abdominal wound sepsis
•preparation of the abdominal wall for secure closure

38. High output enterocutaneous fistula: a literature review and a case study Chung Yan Tong RD, et allAsia Pac J Clin
Nutr 2012;21 (3):464-469

39. High output enterocutaneous fistula: a literature review and a case study Chung Yan Tong RD, et allAsia Pac J
Clin Nutr 2012;21 (3):464-469

40. Summary
• Overall objective of treatment is to increase the probability of spontaneous closure.
• Nutrition and time are key components of this approach.
• Most patient require TPN, however trial of oral or enteral nutrition should be
attempted in pateints with low output fistulas originating from distal intestine.
• Early resuscitation, nutrition supplement, sepsis control, skin care and abscess
drainage within first 24 to 48 hours of identification.
• Define anatomy and characteristic of fistula in 7- 10 days.
• Decide regarding likelihood of spontaneous closure or which needs operative
intervention (10 days to 6 weeks) studying the clinical course of the patient and
imaging modalities.
• Somatostatin analouge octreotide useful adjunct for high output fistula.

41. After sepsis control approximatele 60-90% of
extenal intestinal fistulas with favorable
factors will close spontaneously with
medical management
90% will close with 4-6 weeks and less than
10% in 2-3 month

42. References
1. Maingot’s Abdominal operation 11th edition
2. Surgery updates 2014 (XXXI National CME in Surgery) Department of surgery Maulana
Azad Medical College, New Delhi
3. High output enterocutaneous fistula: a literature review and a case study Chung Yan Tong
RD, et allAsia Pac J Clin Nutr 2012;21 (3):464-469
4. Management of Enterocutaneous Fistulas Manish Kaushal, F.R.C.S. and Gordon L. Carlson,
B.Sc., M.D., F.R.C.S.
5. Historical Perspectives in the Care of Patients with Enterocutaneous FistulaJonathan B.
Lundy, M.D.and Josef E. Fischer, M.D.
6. Nutritional Support In Enterocutaneous Fistula .Sanjay Singh Negi, Shivendra Singh,
Adarsh Chaudhary Department of Gastrointestinal Surgery, G.B. Pant Hospital, New Delhi
7. The Art of Fistuloclysis:Nutritional Management of Enterocutaneous Fistulas Carol Rees
Parrish, R.D., M.S., Series Editor PRACTICAL GASTROENTEROLOGY SEPTEMBER
2010

43. Thank you

44. • Special thanks toDr dipendra
shrestha and Dr. aakriti sharma

45. Phase 4: Definitive Management
• the definitive operative reconstruction of these complicated
patients requires the commitment of significant time and
resources
• team of plastic and reconstructive surgeons should be involved
in the planning and performance of the procedure and should
be consulted preoperatively with enough time to plan the
reconstructive procedure

46. Preliminaries..
• optimal nutritional parameters and be free of all signs of
sepsis.
• Through careful management of fistula drainage, a well-healed
abdominal wall without inflammation should be present.
• Prophylactic antibiotics should be administered based on the
patient's previous microbiological data
• tube feedings should be tapered in the days preceding
operation to allow mechanical and antibiotic preparation of the
bowel.