A presentation on the areas of concern in the management of patients with enterocutaneous fistulae beyond care of the point of leak

1. DISCUSS THE SYSTEMIC
DISTURBANCES OF HIGH
INTESTINAL FISTULA AND OUTLINE
THE PRINCIPLES OF
MANAGEMENT
DR ECHEBIRI,P.
Supervised by
DR BATTA
Department of Surgery,
National Hospital , Abuja
9th November, 2015.

2. OUTLINE
 INTRODUCTION
 PATHOGENESIS
 SYSTEMIC DISTURBANCES OF HIGH
INTESTINAL FISTULA
 MANAGEMENT
 COMPLICATIONS
 FOLLOW-UP
 PROGNOSIS
 PREVENTION
 ADVANCES
 CONCLUSION.

3. INTRODUCTION
Definition
 Intestinal Fistula: It is an abnormal tract establishing a
connection between the epithelium of the lumen of the
gastrointestinal tract and another epithelial surface and
which is lined by granulation tissue.
 High Intestinal Fistula: A fistula in which the internal
orifice is near to the duodenal ampulla
 Epidemiology: Approximately 80-90% of all intestinal
fistulas occur because of operative intervention.

4. INTRODUCTION…
 Statement of Surgical importance
Intestinal fistula is a life-threatening condition whose
management is challenging to the surgeon and
distressing to the patient and their relatives.
 Brief Historical Background
SUSHRUSTA [450B.C]- Resection and anastomosis
for enterocutaneos fistula

5. INTRODUCTION…
FABRICIUS HILDANUS [1597] Spontaneous closure of
Enterocutaneous fistula from Richters hernia after 2
months
 Eras in Management of Enterocutaneous fistula:
1945-1960 : Antibiotics Use [Mortality 45%]
1960-1970: Intensive care nursing[Mortality 15%]
1970-1975: Intravenous hyperalimentation[Mortality
15%]

6. INTRODUCTION…
Classifications
 Anatomical
 Physiological
 Aetiopathological
 Chronological
 Degree of peritoneal contamination

7. INTRODUCTION…
Anatomical Classification
 Stoma Site:
-Internal.
-External
-Mixed.
 Nature of track:
-Simple : single, no associated abscess cavity
-Complex: multiple, co-existing abscess cavity
 Involved circumference of bowel wall:
-Lateral.
-End.
 Section of gastrointestinal tract involved:
-Proximal- near to the duoedenal ampulla
-Distal- distant from the duodenal ampulla

8. INTRODUCTION…
SCHEIN’S MODIFICATION OF SITGES AND SERRA
 Type 1- Abdominal Oesophageal & Gastro duodenal
fistulas[17% mortality]
 Type 2- Small bowel fistula.[33% mortality]
 Type 3- Large bowel fistula.[20% mortality]
 Type 4- Fistula at any site with associated large
abdominal wall defect.[60% mortality]

9. INTRODUCTION…
IRVIN AND BEADLE
 Type 1-A single orifice passing through an intact
abdominal wall or healed scar with normal surrounding
skin
 Type2-Single or multiple orifices passing through
abdominal wall close to bony prominence, surgical scar,
umbilicus or other stoma.
 Type3-Fistula presenting through a small dehiscence of
the main wound.
 Type4-Fistula presenting through a large dehiscence or at
the bottom of a gaping wound.

10. INTRODUCTION…
Physiological Classification
High Output :
 Drainage > 500ml/24hr [pancreatic and biliary
fistulas > 200ml/24hr]
Moderate Output:
 Drainage 200-500ml/24hr
Low Output:
 Drainage < 500ml/24hr [pancreatic and biliary
fistulas < 200ml/24hr]

11. INTRODUCTION…
Aetiopathological Classification
CONGENITAL
 Patent Omphalomesenteric duct
 High Anorectal malformation with fistula
ACQUIRED
 Postoperative [75-85%]
 Spontaneous[15-25%]
 Trauma[< 5%]

12. INTRODUCTION…
Surgeries likely to lead to fistula
 Emergency surgeries
 Surgery for Peptic Ulcer Disease, Cancer
 Minimal access surgeries.
 Placement of foreign bodies like mesh
 Adhesiolysis
 Herniorraphy

13. INTRODUCTION…
Other causes of fistulas
Spontaneous
 Inflammatory: Tuberculosis,Crohn’s disease,
Amoebiasis
 Malignancies: Colorectal, Ovarian cancer
 Radiation enteropathy
Post-traumatic
 Blunt: Motor Vehicle Accident
 Penetrating: Gunshot wounds, Impalement injuries

14. INTRODUCTION…
Chronological Classification
 Early:< 5 days post-operatively
 Late: ≥ 5 days post-operatively
degree of peritoneal contamination
 Controlled: No/minimal peritoneal soiling
 Uncontrolled: Considerable peritoneal soiling

15. INTRODUCTION…
Relevant Anatomy/Physiology
Small Intestine: about 280-300cm in length and
extends proximally from the pylorus to the ileocaecal
valve. Comprises the Duodenum, Jejunum and Ileum
Large Intestine: About 100cm long and extends from
the Ileocaecal valve to the anal verge.

16. INTRODUCTION…

17. INTRODUCTION…
Functions of the Intestine.
 Secrete hormones and digestive juices
 Digest nutrients in food such as
Carbohydrates,Proteins and Lipids
 Absorb products of digestion and other substances
including drugs
 Expel undigested food, unabsorbed products,
bacteria and shed epithelial cells as faeces

18. INTRODUCTION…
Source Volume(ml/
day)
Na
(mmol/L)
K (mmol/L) Cl
(mmol/L)
HCO3
(mmol/L)
Saliva 1500 10 26 15 50
Gastric 2500 100 10 100 0
Duodenal 200 130 5 90 10
Biliary 1000 150 5 100 35
Pancreatic 1000 140 5 75 115
Ileal 3000 140 5 100 30
Composition and Volume of Intestinal Secretions

19. PATHOGENESIS
Contributory factors
 Best illustrated by post-operative fistulas
 They are: local, systemic and technical
Local factors:
 Poor wound blood supply.
 Distal obstruction.
 Diseased bowel.
 Surgical Site Infection(SSI)

20. PATHOGENESIS
Systemic factors:
 Malnutrition.
 Sepsis.
 Steroid therapy.
 Immunosuppression.
Technical factors
 Unrecognised bowel injury
 Tight suture causing ischaemic necrosis
 Bowel devascularisation
 Poor haemostasis
 Inappropriate use of drains
 Foreign bodies like mesh

21. PATHOGENESIS
Intestinal fistula leads to partial or complete interrruption of
bowel continuity with resultant exposure of extraintestinal
tissues to bowel flora, and loss of bowel contents including
fluid, electrolytes, and ingested food.

22. SYSTEMIC DISTURBANCES
 Dehydration
 Electrolyte derangements
 Malnutrition
 Sepsis
 Anaemia
 Immunosupression
 Psychological trauma.

23. SYSTEMIC DISTURBANCES
Dehydration
 8 to 10 Liters of fluid flows through the intestine
each day
 Only 100 to 200 mL of fluid is excreted in the stool.
 Large fluid volumes exit through high fistula
 Severe dehydration invariable without intervention.
 Thirst, small volume concentrated urine, sunken
eyes, dry skin and mouth
 Progression to shock

24. SYSTEMIC DISTURBANCES
Electrolyte derangement
 Electrolytes inevitably accompany fluid and are lost
 Electrolytes mainly affected are Sodium,
Potassium, Chloride, Bicarbonate, Calcium and
Magnesium
 Electrolyte content of fistula drainage varies with its
level for example Duodenal fistula- Hypokalemic,
Hypochloremic alkalosis

25. SYSTEMIC DISTURBANCES
Electrolyte derangement
 Hyponatremia may lead to cerebral oedema with
malaise, headache, vomiting, convulsion,
respiratory distress due to pulmonary congestion
 Hypokalemic features include muscle weakness,
lethargy, paralytic ileus, slurred speech, cardiac
arrhythmias, hypotension, cardiac arrest.
 Hypocalcaemia/Hypomagnesaemia are associated
with coarse irregular tremors, muscular twitches,
abdominal cramps, convulsions, paralytic ileus

26. SYSTEMIC DISTURBANCES
 ventricular arrhythmias, behavioural disturbances,
depression,delirium.
 In hypocalcemia Trousseau’s and Chvostek’s signs
may be positive
Malnutrition:
 It is common and severe
 Factors responsible include
- Loss of nutrients in drainge
- Loss of digestive juices
- Reduced oral intake due to anorexia and nausea
- Insufficient absorptive surface
- Hypercatabolism

27. SYSTEMIC DISTURBANCES
Malnutrition…
 Features: Generalised weakness, weight loss, fluffy
hair, brittle nails, cheilitis, glossitis, anaemia, poor
wound healing, bronchopneumonia due to
weakness of respiratory muscles
Sepsis
 Commensal bowel flora proliferate as well as
contaminate extraintestinal tissues along fistula
tract.
 Abscess cavity in association with fistula tract
increases the severity of sepsis

28. SYSTEMIC DISTURBANCES
Sepsis:
 Uncontrolled fistula leads to peritonitis and
progresses rapidly to septic shock and multiple
organ dysfunction.
 Sepsis is characterised by fever, chills, prostration,
respiratory distress, tacchycardia
Anaemia:
 Malnutrition,Sepsis,frequent blood sampling for
investigations, fistula haemorrhage are implicated

29. SYSTEMIC DISTURBANCES
Anaemia:
 Features include generalised weakness, dizziness,
palpitations, easy fatigability, dependent body
swelling, and high output cardiac failure with cough,
orthopnea, arrhythmias
Immunosupression:
 Above-mentioned Systemic changes culminate in
compromising patients immunity.

30. SYSTEMIC DISTURBANCES
Psychological Trauma:
 The sight of enteric matter spilling forth from the
abdomen is not one guaranteed to reassure the
patient or his relatives.
 Patient loses confidence in the Surgeon, becomes
dejected and depression sets in

31. CLINICAL FEATURES
 Presentation may be emergency in which case
resuscitation is promptly commenced while assessing the
patient; or elective
 There may be a history of recent laparotomy with possible
resection & anastomosis
 Onset of localized or generalized abdominal pain & fever
few days after; usually 4th-5th day post-operatively

32. CLINICAL FEATURES
 Discharge from the main wound or drain site which is
initially serosanguinous,then purulent.
 Discharge of intestinal contents after release of few stitches
 History sugestive of underlying disease such as
Amoebiasis, Crohn’s disease,Abdominal Tuberculosis or
Malignancy
 History of radiotherapy for abdominal tumours

33. CLINICAL FEATURES
General Examination:
 Chronically ill-looking
 Palor
 Dehydration
 Icteric
 Pyrexia
 Peripheral Lymph nodes enlargement
 Pedal Oedema

34. CLINICAL FEATURES
Anthropometry: Weight, Height, Body Mass Index,
Triceps skin fold thickness, Mid-arm circumference
Respiratory System:
 Respiratory distress
 Features of Pulmonary Tuberculosis
Cardiovascular System: Haemodynamically unstable

35. CLINICAL FEATURES
Abdomen:
 Orifices: Single or multiple, narrow or wide
 Nature of effluent:
-Duodenojejunal effluent usually bilous & cause
severe skin irritation
-Ileocaecal effluent usually
yellowish & frothy, fluid faeces
-Colonic effluent usually solid or
semi-solid frank faeces

36. CLINICAL FEATURES
Abdomen…
 Peri-stomal skin: Erythema, macerated, excoriation
 Tenderness
 Guarding or rigidity or rebound tenderness

37. INVESTIGATIONS
 An Intestinal fistula is usually obvious.
 Certain investigations may be indicated as follows:
 Serum Chemistry: Serial monitoring to ensure correction
of derangements
 Serum Proteins especially Albumin, C-Reactive proteins,
Retinol binding proteins, Thyroxin binding prealbumin,
Transferin. These are Predictors of closure & mortality.
 Serum transferrin - Low levels (< 200mg/dL) and C-
Reactive Protein: <5mg/L are predictors of poor healing.

38. INVESTIGATIONS
 Full Blood Count with Erythrocyte
Sedimentation Rate: Haemoglobin less than
10g/dL indicates anaemia. Lymphocytes < 1500/ml
is poor prognostic factor
 Ultrasonography: Abscess cavities
 Computed Tomography scan: Complicated fistula
with tortuous tracts
 Isotope studies: Indium-111, Gallium-67
 Chest X Ray: Features of Pulmonary Tuberculosis
 Endoscopy & Biopsy: Malignant fistula

39. INVESTIGATIONS
 Barium contrast studies
Barium meal & follow through

40. INVESTIGATIONS
 Fistulography: Gastrograffin,hypaque or lipiodol
- Outlines fistula tract
- Level of connection with gut
- Delineates abscess cavity,
- Shows distal obstruction
 Bed side markers: Oral non absorbable coloring agents
such as methylene blue,congo
red,Indigo Carmine or activated charcoal

41. PRINCIPLES OF MANAGEMENT
 Rehydration
 Correction of Electrolyte derrangements
 Correction of Anaemia
 Nutritional Rehabilitation
 Control of Infection
 Control of Fistula drainage
 Skin protection and care
 Counselling and psychological support
 Definitive treatment

42. TREATMENT
 The aim of management is to achieve fistula
closure and a patient who is healthy
 Patient may present present as emergency in which
case RESUSCITATION alongside clinical
assessment and monitoring investigations go on
simultaneously until stabilisation.
 Challenging in high fistula
 Treatment is multidisciplinary involving Surgeons,
Nurses, Nutritionist, Stoma therapist

43. TREATMENT…
Rehydration:
 Using crystalloids like Normal saline infused
intravenously
 Correct for deficits plus ongoing losses and daily
maintenance requirements
 Urethral catheterisation and keep an Intake-Output
chart ensuring urine output is 30-50ml/hr
Correction of Electrolyte derrangements:
 Correction is gradual and guided by serial E/U/Cr.

44. TREATMENT…
Correction of Electrolyte derrangements…
 Aim is restore normal serum levels of elctrolytes
 For example correction of hypokalemia may be
done with Potassium chloride added to Intravenous
fluid after ensuring adequate urine output.The
calculated requirement is given preferrably under
electrocardiogram monitoring.

45. TREATMENT…
Nutritional Rehabilitation:
 Aim is to maintain the patient in a positive nitrogen
balance until fistula heals spontaneously or fit for
operative closure.
 Determine energy requirement as follows:
Resting Energy Expenditure(REE) X Stress factor
X Activity factor
 The REE is derived from either the Modified
Harris Benedict equation or Indirect Calorimetry

46. TREATMENT…
Nutritional Rehabilitation…
 Modified Harris-Benedict equation
Male:65.5+[13.8* Wt in Kg]+[5*Ht in cm]-[6.8*Age
in yrs]
Female:65.5+[9.6*wt in kg]+[1.9*ht in cm]-[4.7*Age
in yrs]
 Indirect calorimetry
[3.9*VO2] + [1.1*VCO2]+ [2.2*Urine nitrogen]

47. TREATMENT…
Nutritional Rehabilitation…
 Patients with localised infection and
malnutrition need 30-40 kcal/kg/day.
 Patients with uncontrolled sepsis, shock and
multiple organ failure need 40-45 kcal/kg/day.
 Energy requirements usually 2000-3000kcals/day
 Proteins are given at 1.5-2.5g/kg/day but they are
not used in the calculation of daily caloric
requirements to enable protein sparing and initiate
anabolism.

48. TREATMENT…
Nutritional Rehabilitation…
 Maintain Calorie: Nitrogen = 150-200:1
 Add twice Recommended Daily Allowance(RDA) for
vitamins & trace elements.
 10 times RDA of Zinc and Vitamin C.
 Calculate requirement every day.
 Parenteral Nutrition is the mainstay of nutritional
rehabilitation of high intestinal fistulas
 It reduces the maximal secretory capacity of the
gastrointestinal tract by 30–50%.

49. TREATMENT…
 Promotes favourable conditions for closure.
however ;
 Complications are potentially catastrophic.
 It does not suppress basal or cephalic secretions and may
stimulate gastric and intestinal secretions during long-term
administration.
 It may be administered as Total or Partial Parenteral
Nutrition
 1L of fluid=1000 calories . Usually 3L is given daily. Add
insulin to drive the calorie into tissues.
 Normally TPN is given gradually
1L = Day 1
2L = Day 2
3L = Day 3 and above

50. TREATMENT…
Nutritional Rehabilitation…
 Observations to be made during TPN:
- -Daily clinical assessment including Intake-Output
chart
- -Blood sugar daily initially then twice weekly later
- -E/U/Cr and Clotting studies every 48 hours
- -Liver Function Test, Calcium, Full Blood Count
weekly
 Enteral nutrition (EN) is included wherever possible
as it helps maintain gut integrity.

51. TREATMENT…
Nutritional Rehabilitation…
 EN is adminitered orally or via tube-feeding:
Pre/Post-Pyloric acess, fistuloclysis, enterostomies.
Anaemia: is corrected by periodic blood transfusion
based on serial FBC
Control of infection: Antibiotics, Antifungals and
Percutaneous imge-guided drainage as indicated

52. TREATMENT…
Control of Fistula drainage: Involves use of
pharmacological agents to reduce secretory activities
of gastrointestinal tract
 Beneficial in minimising dehydration and
electrolytes derangements
 Agents include H2 receptor blockers, Proton pump
inhibitors, Somatostatin,Octreotide
Skin protection and care: For a high-output fistula, a
pouch system is preferable to a conventional barrier
skin dressing
 Skin dressings include Zinc Oxide, Silicone cream,
Karaya

53. TREATMENT…
Definitive Treatment:
 More than 90% of all fistulae will close spontaneously
within 4-6 weeks on Non-operative management
 Less than 10% close after 8 weeks.
 Spontaneous closure is unlikely after 12 weeks.
 Fistulas associated with disease conditions in addition
benefit from specific therapies for example Infliximab,
Azathioprine in Crohn’s fistula
 Indications for operative intervention may be emergency
or elective

54. TREATMENT…
Emergency indications
 Generalised peritonitis
 Undrained abscess not amenable to CT or Ultrasound-
guided drainage.
 Complete intestinal obstruction.
 Uncontrolled fistula bleeding.
 Presence of foreign body like forceps, gauze
 Creation of feeding enterostomies

55. TREATMENT…
Elective indications
 presence of factors preventing spontaneous closure
 failure of conservative treatment
 in a controlled fistula, if continued non-operative treatment is
considered expensive

56. FACTORS AGAINST SPONTANEOUS
CLOSURE OF FISTULA
 High output fistulae
 Distal obstruction
 Inflammatory bowel disease at site of fistula
 Abscess cavity
 Radiation
 Foreign body
 Epithelialization of the tract
 End-fistula
 Large abdominal wall defect
 Fistula tract > 2.5cm long

57. PRINCIPLES OF ELECTIVE FISTULA
SURGERY
PRE OPERATIVE
 Optimal nutritional parameters.
 Free of sepsis.
 Well-healed abdominal wall without inflamation.
 Prophylactic antibiotics.
 Tapering down of enteral feeds.
 Bowel preparation.

58. INTRA-OPERATIVE CONSIDERATIONS
 Placement of incision on virgin skin.
 Adhesiolysis and bowel mobilisation.
 Resection of fistula containing areas and primary
anastomosis. Serosal patch and omental flap may be
employed

59. INTRA-OPERATIVE CONSIDERATIONS
 Bypass of areas of fistula involving multiple bowel
segments.Roux-en-y bypass is more effective than simple
bypass.
 Exteriorization of bowel ends to create controlled fistula in
presence of unresectable distal obstruction.
 Feeding enterostomy.
 Abdominal wall closure.

60. POST-OPERATIVE CONSIDERATIONS
 Continued nutritional support after fistula closure is
essential to prevent recurrence.
 Rehabilitation of patient and re-integration into the
society
 Follow-up

61. COMPLICATIONS
 Residual abscess
 Re-fistulation
 Anastomotic stricture
 Adhesive small bowel obstruction
 Short bowel syndrome
 Ventral hernia

62. PROGNOSIS
Factor Favorable Unfavorable
Organ of origin Esophageal Lateral duodenal
Duodenal stump Ligament of Treitz
Pancreaticobiliary Ileal
Jejunal
Colonic
Etiology Postoperative Malignancy
Appendicitis Inflammatory bowel disease
Diverticulitis
Output Low (<200–500 mL/day) High (>500 mL/day)
Nutritional status Well-nourished Malnourished
Transferrin >200 mg/dL Transferrin <200 mg/dL
Sepsis Absent Present
State of bowel Healthy adjacent tissue Diseased adjacent bowel
Intestinal continuity Distal obstruction
Absence of obstruction Large abscess
Bowel discontinuty
Previous irradiation

63. PROGNOSIS…
Fistula characteristics Tract >2 cm Tract <1 cm
Bowel wall defect <1 cm2 Defect >1 cm2
Epithelialization
Foreign body
Miscellaneous
Financial status
Pre morbid conditions
Co morbidity
Original operation performed
at same institution
Good
Absent
Absent
Referred from outside
institution
Poor
Present
Present

64. PROGNOSIS…
 Currently, mortality rate is about 10-15%

65. PREVENTION
 Proper pre operative preparation.
-Nutrition.
-Bowel prep.
 Meticulous surgical technique.
-Anastomose only when condition is favourable.
-Consider exteriorization when unfavourable
 Adequate post operative care.
Cardinal Principles of GIT Anastomosis
 Avoid tension across anastomosis

66. PREVENTION
Cardinal Principles of GIT Anastomosis…
 Ensure good blood supply to both ends of the
bowel
 Achieve accurate and watertight apposition – good
bites, close sutures
 Limit contamination & prevent sepsis
 Exclude distal obstruction

67. ADVANCES IN FISTULA REPAIR
 Fibrin glue.
 Histoacyl
 Vacuum-assisted closure.
 Laparoscopic repair.

68. CONCLUSION
 Management is challenging and frustrating, but could be
ultimately rewarding.
 Most uncomplicated fistula will close spontaneously with
control of sepsis & nutritional support.
 Critical to recognise when operative intervention is
expedient.

69. REFERENCES
 Badoe E.A, Nwako, Tandoh J.F.K, Archampong
E.Q, Et al. Small and Large intestines (including
Rectum and Anus). In BadoeE.A, Principles and
Practice of Surgery including pathology in the
tropics, 4th ed. Accra: assemblies of God literature
centre; 2009.p650-737
 Brunicardi F.C, Editor-in-Chief. Schwartz principles
of Surgery. 10th ed. New York; 2010
 Norman S.W, Christopher J.K.B, Ronan P.O Ed
Bailey and Love’s Short Practice of Surgery. 25th
ed. London: Hodder Arnold; 2008.

70. REFERENCES
 Beuchamp, Evers, Mattox. Sabiston Textbook of
Surgery. The Biological Basis of Modern Surgical
Practice. 19th Edn
 Ajao OG. Ladipo. JK, Adebamowo CA.
Enterocutaneous fistula: Ibadan experience. Intl. J
Trop Surg 1991; 2: 48-52.
 Sitges-Sera A, jaurrieta E, Stiges-Creus A.
management of postoperative enterocutaneous
fistula: the role of parenteral nutrition andsurgery.
Br. J. Surg. 1982;69: 147-50.
 Schein M, Decker GAG. Postoperative extrernal
alimentary tract fistulas. The Amer J Surg. 1991;
116:435-8.

71. REFERENCES
 Schein M and Decker GAG. Gastrointestinal fistulas
associated with large abdominal wall defects:
experience with 43 patients. Br. J Surg 1990; 77:
97-100.
 Kuvshinoff BW, Brodish RJ, McFadden DW, Fischer
JE. Serum transferrin as prognostic indicator of
spontaneous closure and mortality in
gastrointestinal cutaneous fistulas Ann Surg 1993;
217: 615-23.

72. ABOVE ALL ELSE, IT IS INSTRUCTIVE TO ALWAYS REMEMBER TO
TREAT THE PATIENT AS “A WHOLE ENTITY”
NOT AS “A HOLE ENTITY”
THANK
YOU