Доклад с 15 Межрегиональной научно-практической конференции "Искусственное питание и инфузионная терапия больных в медицине критических состояний" 21-22 мая 2015 г

1. Do’s and Don’t’s in the
management of intestinal
fistulae
St. Petersburg, Russia
Peter B. Soeters
the Netherlands

2. Enterocutaneous fistula
• Abnormal communication between the intestinal tract and the skin
or a hollow organ

3. • Mrs. Van der G., 62 years old, 1.68 m, 58 kg
• no serious comorbidity, admitted to the emergency ward
elsewhere
• abdominal pain for 3 days, vomiting and no passage of
stools since three days, no fever.
• Medical history
• Hysterectomy (removal of the uterus) 20 years earlier
because of uncontrollable meno-, metrorhagies (bleeding).
• Since years recurrent crampy pain and slight bowel
distention with audible bowel sounds. This has been
become worse and at times she has been anorectic.
• Physical examination
• Slight distension of the abdomen, no bowel sounds
• Tenderness and rebound tenderness in the abdomen but
especially in the left upper quadrant .
• Clinically dehydrated.
• Plain X-ray films of the abdomen in standing position:

4. X- abdomen confirms
the diagnosis small
bowel obstruction

5. P.o. day -2 y to -9
At Home
-1d
Elsewhere
9d
MUMC
25d
MUMC
50d
MUMC
Hb mmol
N ± 7.3 – 8
7,1
Leuco’s/fl 23
Alb g/L
N ± 40
31
Kreat µM/L
N ± 80
153
BW kg 66-58 60
• Is the Hb normal?
• Is she malnourished?

6. What is Malnutrition?
A nutritional state resulting from a
combination of varying degrees of
undernutrition and inflammatory
activity and leading to abnormal
body composition and diminished
function

7. Three types of function = Quality of Life
•Muscle function
•Strength
•Reservoir of substrate to support an
adequate metabolic response to
trauma/disease
•Immune function
•Allowing to generate an inflammatory (=
healing) response
•Cognitive function
•To allow thinking, remembering, feeling
well, managing life etc

8. Nutritional Assessment
=
Risk Assessment

9. Kudsk et al,
JPEN 2003
27: 1-9

10. P.o. day -2 y to -9
At Home
-1d
Elsewhere
9d
MUMC
25d
MUMC
50d
MUMC
Hb mmol 7,1
Leuco’s/fl 23
Alb g/L 31
Kreat µM/L 153
BW kg 66-58 60
?
Why does Bodyweight (BW) increase from 58 to 60 kg?

11. Mrs. van der G., 62 y old at the emergency ward
Questions:
•Mrs. van der G. is dehydrated. How do you
rehydrate her?
•Mrs. van der G. is malnourished
•Does she need an operation and if so does
she need preoperative nutrition? Or is she
so ill that she needs an operation acutely?

12. After 6 hours of preparation (rehydration, nasal tube
suction, high rectal enema):
• No improvement of bowel function
• Immediate operation
• Volvulus of one of the first loops of the jejunum, necrotic.
• Generalized peritonitis.
• Resection of the loop (50 cm) and primary anastomosis.
Questions:
• Is this wise?
• Would you have done something differently?
• Which nutritional regimen do you prescribe and when should this be
started?
• Would you have created a gastrostomy or jejunostomy to feed?

13. Immediate postoperative course
• No improvement, patient remains ill
• Much fluid support is necessary to keep urine production up
• Fever
• Nasal stomach tube: approximately 1600 ml/24h comes out
• Tube feeding is impossible.
• After 5 days the midline incision opens due to a wound
abscess; dehiscence of the abdominal wall.
• Development of an acute respiratory insufficiency.
9 days after operation she is transferred to the Maastricht
University Medical Centre (MUMC), the Netherlands to the
ICU.

14. What are the priorities of treatment?
SOWATS guideline
•Treatment concept
•Sepsis control
•Optimization of nutritional state
•Wound care
•Anatomy of the fistula
•Timing of surgery
•Surgical strategy
Visschers, R. G., et al. (2008). "Treatment strategies in 135 consecutive patients with
enterocutaneous fistulas." World J Surg 32(3): 445-453.

15. •She barely escapes artificial ventilation.
•A CT scan is made of the abdomen.
SOWATS guideline: Sepsis control

17. Mrs. van der G., 62 y old, 9 days after operation
•CT scan abdomen: intra-abdominal abscess.
•Abcess drainage via a small surgical incision after
radiologic puncture drainage had failed
•A day later:
• Discharge of bile through the small wound.
• In a few days a high output fistula develops (over 1500
ml per day) draining like a loop jejunostomy.
• The fistula arose from lesions caused by the dissection of
inflamed intestine (peritonitis) or from the anastomosis
during the earlier operation.
•Questions:
•How do you nourish her?
•Which nutrients can still be adequately absorbed in
the 50 cm of intact jejunum that is still in
continuity with the oesophagus, stomach and

18. Medical Physiology
Boron, Boulpaep
Saunders
High output jejunal fistula

19. In the two following weeks (3 ½ weeks
after admittance) almost all organ
functions improve (Improvement of
respiratory and renal function, and
discontinuation of inotropic support)
Fistula output increases to 2000-2500
ml/24h.

20. P.o. day -2 y to -10
At Home
-1d
Elsewhere
9d
MUMC
25d
MUMC
50d
MUMC
Hb mmol 7,1 5,6 6,7
Leuco’s/fl 23 18 11
Alb g/L 31 15 23
Kreat µM/L 153 120 56
BW kg 66-58 60 65 56
Why does albumin increase?
Why does the body weight decrease?

21. •In the two following weeks (3 ½ weeks after
admittance) almost all organ functions improve
(Improvement of respiratory and renal function,
and discontinuation of inotropic support) Fistula
output increase to 2000-2500 ml/24h. But ………..
Mrs vd G. gets jaundiced (yellow skin).
• Alk Phosphatase 4x elevated
•  GT 4x elevated
• Direct Bilirubin 230 µmol
• Transaminases slightly elevated
• Triglyceride levels 3-4 mmol
• Inflammatory parameters modest inflammation.
• Albumin > 23 g/l without Albumin infusion.

23. Rinsema et al
SGO 1988 167: 372-6

24. Rinsema et al, SGO 1988
Rinsema W, Gouma DJ, von Meyenfeldt MF, Soeters PB. Reinfusion of secretions from
high-output proximal stomas or fistulas. Surg Gynecol Obstet. 1988;167(5):372-6.

25. Activation of the Nuclear bile acid receptor
(Farnesoid receptor; FXR) with bile :
• Diminishes intestinal inflammation, liver cholestasis and
steatosis when activated by
• Re-establishing primary bile acid pool by
operation/reinfusion or UDCA, CA, norUDCA
• Synthetic FXR activators
• Improves intestinal integrity
• Decreases Triglyceride and Cholesterol content in the liver
and VLDL assemby
• FXR deletion/ malfunction increases fat content of the liver

26. Nutritional support:
• 1000 ml of enteral formula feeding per day together with a large part
of the proximal pancreatic and biliary secretions.
• PN is diminished to 1000 ml/d without lipid.
• 2x/week 500 ml 10% lipid emulsion
• 0,5-1.0 litres of balanced salt solution supplemented with Mg, Ca, Zn
=> electrolytes normalize.
After three weeks:
• Alk Phosphatase High range of normal
• Gamma- GT High range of normal
• Direct Bilirubin 20 µmol (high range of normal)
• Transaminases Normal
• Triglyceride levels 1-2 mmol (2x/week 500 ml 10% lipid
emulsion)
• Inflammatory parameters CRP 20 mg/L
• Albumin > 25 g/l without Albumin infusion.

27. P.o. day -2 y to -10
At Home
-1d
Elsewhere
9d
MUMC
25d
MUMC
50d
MUMC
Hb mmol 7,1 5,6 6,7 7,8
Leuco’s/fl 23 18 11 7,5
Alb g/L 31 15 23 32
Kreat µM/L 153 120 56 63
BW kg 66-58 60 65 56 56
Why does she not gain weight?
How does her body composition change?

28. •Physical, cognitive and biochemical improvement.
•Alb, Hb, rise.
•Intrahepatic cholestasis/jaundice disappear
completely.
•35 days after operation transfer from ICU to normal
ward.
•Physiotherapy was started in ICU and continued in
physiotherapy ward.
• 56 days after her first operation reoperation:
•Jejunal fistula is closed
•Abdominal wound is closed. The skin is left open.
•Mrs B. resumes oral intake a few days after the
operation and is discharged 70 days after her
admittance to the ICU.

29. SOWATS: Optimization of nutritional state
•± 70% of fistula patients are severely
malnourished
•Inadequate food intake and malabsorption
•Catabolism due to inflammation/infection
•Short bowel
•Malnutrition leads to:
•Bad healing of wounds
•Bad healing of anastomoses
•Lack of bile in the bowel leads to
inflammation in the bowel and in the liver

30. SOWATS: Optimization of nutritional state
•Total parenteral nutrition when fistula may
heal spontaneously; some enteral (500 ml)
•Always enteral if possible:
•when fistula will not heal spontaneously
•when fistula output does not damage the
wound
•add parenteral nutrition when not enough
enteral can be given or absorbed
•Physiotherapy

31. Development of enterocutaneous fistula
Spontaneous or surgical perforation => abcess
=> rupture/drainage abscess to skin or other
organ=> fistula
Formation Cause
Spontaneous
10-25%
Crohn’s disease
Cancer
Diverticulitis
Radiation enteritis
Surgical
75-90%
Iatrogenic lesion (sutures)
Anastomotic failure
Abdominal wall dehiscence
Mesh rupture
Drain puncture
Traumatic
<5%
Diagnostic intervention (puncture)
(Traffic) accident
Gun shot wound
Knife injury

32. Enterocutaneous fistulas
•Small bowel fistulas:
•Frequently high output
•Short bowel => malabsorption =>
metabolic disturbances
•=> metabolic disorders
•Malnutrition
•Dehydration
•Electrolyte disorders
•Cholestasis/ fatty liver
•Mucosal inflammation

33. Mortality in fistulas
•In the past:
•Sepsis
•Lack of nutritional support
•Fluid and electrolyte imbalance (especially
in the past)
•At present:
•Sepsis

34. Advances in treatment
•Parenteral/Enteral nutrition techniques
•Intensive care medicine
•Surgical technique
•Radiology (Ct and others) and
intervention
•Intestinal failure unit/ teams
•Management skills

35. Current treatment strategy
•There are no randomized controlled trials
(possible) but treatment is based on
cohort studies, case reports and expert
opinion from specialized referral centers
•Development of standardized treatment
strategies (protocol/guidelines)

36. SOWATS: Sepsis leading to organ disfunction
and malnutrition
•Most often cause of death in fistula patients
•Often due to inadequate drainage
•Treatment first priority
•Preferably CT-guided puncture of abscesses
•Prevent complete laparotomy if possible
because of many complications at this
moment
•Only antibiotics have little effect, should be
based on cultures but are ineffective in the
presence of major abscesses.

37. Diagnosis fistula in case of fluid
drainage of unknown origin
•Food substances (e.g. fiber)
•High concentrations of bilirubin/amylase
•Puncture abdominal fluid:
•Gram stain and culture
•Alb (low when intestinal content)
•Creat, amylase, bilirubin
•Cytology when malignancy possible
•Radiology

38. Signs of sepsis improvement
•Patients feel better
•No fever
•Disappearance of edema/ drying up
•Negative fluid balance
•Wrinkling of the skin
•Interest in surroundings
•Much stronger, gets out of bed
•Becomes impatient, wants to be operated
•Hb, Alb increase
•CRP, Sedimentation rate, Leucocytes decrease

39. Enteral Nutrition
•How much bowel is necessary to take up
enough nutrition by enteral route?
•> 200 cm small bowel without colon
•> 50-150 cm small bowel with colon
•When long segment (75-100 cm) distal small
bowel excluded:
•Re-infusion of (high) output from the
entero-cutaneous fistula

40. Parenteral nutrition
•Main goal:
•Maximize nutritional status
•Decrease fistula output by limiting
enteral nutrition
•Bridging to surgical closure
•Makes wound care easier
•Allows easier spontaneous closure

41. SOWATS: Wound care
•Low output < 500 ml, high output > 500 ml/day
•Intestinal fluid loss = loss of fluid and electrolytes
•Proteolytic activity of intestinal enzymes requires:
•In small wounds with low output fistula barrier and
keeping skin dry
•Large abdominal wall defects with high output fistulas
treatment with wound bags and sump suction drainage
•No vacuum devices on exposed bowel
•Proton pump inhibitors to diminish gastric secretion
•No significant effects of Somatostatin analogues
•Motility inhibitors (Imodium, Loperamide)

42. Wound care (of another patient)
• Daily inspection and care
• Stoma / wound care nurses
Day 0 Day 0 Day 7 Day 49

43. SOWATS: Anatomical evaluation

44. Spontaneous closure
Overall spontaneous
closure rate 20-30%
•Usually occurs
within 30 days after
development of the
fistula
•When spontaneous
closure does not
occur surgical
treatment is
generally needed
Negative predictors
for spontaneous
closure
• Major dehiscence of the
anastomosis
• Short fistula tract
• Distal obstruction
• Epithelialised fistula tract
• Sepsis or nearby abscess cavity
• High output ECF
• Chronic ECF
• Fistula in an open abdominal
wound
• Non-surgical cause
• Referrals
• Jejuno-ileal ECF

45. SOWATS: Timing of surgery
•Wait at least 6-12 weeks before performing
restorative surgery to allow the abdomen to
become accessible again
•Sepsis should be controlled
•Dry, loss of edema, wrinkling of the skin
•Biochemical parameters (albumin > > 25
g/L)
•Adequate nutritional status
•Clinical parameters (muscle, immune,
cognition)

46. SOWATS: Surgical closure
•Performed in 60-80% of patients
•Successful in 85-90% of cases in centers
•45-70% of the overall closure rate
•Resection of fistula tract and diseased bowel
•Reconnection of the intestine
•Sutures surrounded by healthy tissue, not
exposed to other suture lines or wound
closure
•Closure of the abdominal wall with fascia or
Vicryl mesh

47. Overview reviewed/ treated series
0
10
20
30
40
50
60
70
80
90
100
'46-'59 '60-'70 '70-'75 '77-'87 '90-'05
reviewed period
%patients
mortality overall closure rate (%)
Edmunds, Williams, Welch: Ann. Surg. 1960
Soeters, Fischer, Franklin: Arch. Chir. Neerl. 1977
Soeters, Ebeid, Fischer: Ann. Surg. 1979
Rinsema, Gouma, von Meyenfeldt, van der Linden, Soeters: Acta Chir. Scand. 1990
Visscher, Olde Damink, Winkens, Soeters, van Gemert: Ann. Surg. 2008
157 119 404 114 135

48. 9 days after operation the following lab parameters are found:
• Hb 5.6 mmol/L
• ESR 36 mm/first hour
• Leucocytes 18/ fliter
• CRP 115 mg/l
• Kreat 120 mol/l
• Albumin 15 g/l
• BUN 9 mmol/l
• Electrolytes
• Na 128 mmol/l
• K 5.6 mmol/l
• Cl 115 mmol
• Liver enzymes
• AF and GTP Slightly elevated
• Transaminases normal
• Bilirubin 19 μmol/l
• Ca 1.7 mmol/l
• Mg 0.41 mmol/l
• Zn 7 mol/l
• Cu 39 mol/l
• Fe 8 mol/l
• Transferrin 2.80 mmol/l
• Triglycerides 2.3 mmol/l

49. Conclusion
•Patients with abdominal catastrophe/
enterocutaneous fistula suffer from multiple
complications
•Treatment is complex and requires
multidisciplinary expertise
•SOWATS approach is necessary
•Consider nutritional and metabolic complications
•Treat sepsis, institute nutrition and
physiotherapy: are crucial elements of treatment
•Timing and art of surgery are also important
•One captain and one deputy captain on the ship