This document provides an overview of enterocutaneous fistulas (ECF), including their classification, etiology, prognosis, investigations, and management. ECF are abnormal connections between the bowel and skin that can form after surgery or trauma. They are classified based on output and can be caused by postoperative complications, trauma, or spontaneous events like malignancy or Crohn's disease. Prognosis depends on factors like output, nutrition, and the state of the bowel and adjacent tissue. Management focuses on treating sepsis, maintaining nutrition via enteral or parenteral routes, protecting the skin, and planning surgical repair once the patient is stabilized.

1. Maj Ajay Kumar
Rresident Surgery
Army Hospital(R&R)

2. OVERVIEW
 Abnormal communication between small or large
bowel and skin
 (Duodenum, Jejunum, Ileum, colon, or rectum)
 Esophagus
 Stomach Different presentation and
 Fistula in Ano and management
 Mortality : 5- 15%(Sepsis, Nutritional
abnormalities, and Electrolyte imbalances)

3. HISTORY
 Celsus (53 BC) : “The large intestine can be sutured, not
with any certain assurance, but because this doubtful
hope is preferable to certain despair; for occasionally it
heals up.”
 John Hunter(mid 19th century) : “In such cases
nothing is to be done but dressing the wound
superficially, and when the contents of the wounded
viscus become less, we may hope for a cure.”
 Edmunds et al : 157 patients( 67 developed ECF
following surgery) Mortality-62% with gastric and
duodenal fistulas, 54% in patients with small-
bowel, and 16% with colonic fistula.

4. CLASSIFICATION
 Low-output fistula (< 200mL/day)
 Moderate-output fistula (200-500mL/day)
 High-output fistula (>500mL/day)
 Determine the prognosis
 High output- Electrolyte imbalance, Malnutrition
Berry SM, Fischer JE. Classification and pathophysiology of enterocutaneous
fistulas. Surg Clin North Am. Oct 1996;76(5):1009-18

5. ETIOLOGY
 Post-operative
 Traumatic
 Spontaneous

6.  Post-operative
 Disruption of anastomosis-blood flow
-tension on anastomotic line
-inadequate mobilization
-min leak-perianastomotic abscess
 Inadvertent enterotomy - adhesions,
- serosal/full thickness tears
 Inadvertent small bowel injury - Occurs during abdominal
closure, especially after ventral hernia repair

7.  Traumatic
 Iatrogenic surgical trauma
 Road traffic accidents
 Spontaneous -20-30% of cases
 Malignancy
 Radiation enteritis with perforation
 Intra-abdominal sepsis
 Inflammatory bowel disease – eg. Crohn disease

8. PROGNOSIS
 90% ECF closed within first month.
 10% with in next TWO months. Remaining unlikely to
get closed spontaneously
Factors preventing the spontaneous closure
 F oreign body
 R adiation
 I nflammation/infection/inflammatory bowel disease
 E pithelialization of the fistula tract
 N eoplasm
 D istal obstruction

9.  Maingot’s Abdominal operation 11th edition
Favourable Not favourable
Organ of origin Oropharyngeal, Esophageal,
Duodenal stump, Jejunal
Colonic
Gastric, Lateral duodenal,
Ileal
Etiology Post-op,
Appendicitis, Diverticulitis
Malignancy
IBD
Output Low(<200-500ml/day) High(>500ml/day)
Nutritional state Well nourished
Transferrin >200mg/dl
Malnourished
Transferrin <200mg/dl
State of bowel Healthy adjacent tissue
Intestinal continuity
Diseased adjacent bowel
Distal obstruction
Fistula characteristics Tract >2cm
Bowel wall defect <1cm 2
Tract <2cm
Bowel defect >1cm2

10.  Skin excoriation

11. INVESTIGATIONS
 Lab studies
 TLC: sepsis
 Serum Na+/K+: Electrolyte abnormalities
 CBC, total proteins, serum albumin, and globulin :
malnutrition-associated anemia/hypoalbuminemia
 Serum transferrin - Low levels (< 200mg/dL) are a
predictor of poor healing
 Serum C-reactive protein - levels may be elevated

12. Fistulogram
Water soluble contrast
 I – Simple, short blind ending, < 2cm
 II - Continuous linear, long single, >2cm
 III - Continuous complex, multiple linear
Tract positions are as follows:
 Anterior - Ventral, 10- to 2-o’clock position
 Posterior - Dorsal, 4- to 8-o’clock position
 Lateral - Right (2- to 4-o’clock position) or left (8- to 10-o’clock
position)

13. CT Scan
 Fistula tracts are not usually visible
on axial CT imaging, although
sagittal or reconstructed images
may provide useful information
 Identify abscesses and guide percutaneous interventions

14. MANAGEMENT
Main Principal of management:- SNAPP
 S- Sepsis
 N- Nutrition
 A-Anatomy of fistula
 P- Protection of skin
 P- Planned procedure

15. Sepsis- most important factor.
65 % of death in ECF pt
 Culture based Antibiotics (consider infection with
fungal organism)
 Intrabdominal collection should be drained
radiological assisted.

16. Nutrition
 Poor enteral intake
 Hypercatabolic septic state
 Loss of protein rich enteral contents
Correction of-
 Dehydration
 Hyponatremia
 Hypokalemia
 Metabolic acidosis

17. Calories :25–32 kcal/kg/day(upto 40-45kcal/kg/day)
(Calorie:nitrogen ratio of 150:1 to 100:1 )
Protein: 1.5-2 gm/kg/day
 Parenteral nutrition followed by early shift to enteral
route
 Fistuloclysis

18. Step-by-Step regimen to control the output:-
 Step 1
- ISOTONIC solution and fluid restriction- pt should be
restricted to total of oral fluid of 1500ml/24hrs out of which
1 liter should be oral electrolyte solution. Remaining 500
ml can be pt choice
- Drinking water should be avoided with in 30 min of meals
 Step2
- PPI- omeprazole 40-80 mg /24 hrs
 Step3
- Loperamide - 4 mg QID to start than go up to 16 mg QID.
and codeine – 60 mg QID
 Step4
- Octreotide- limited evidence of benefit
Start with 200micrgram SC TDS for 48 hrs

19. Protection of Skin:-
 Wound Care- intestinal content are corrosive d/t
proteolyitc enzymes
 Wound manager, vacuum dressing
 Failure to protect skin around the ECF is one of the
indications of early surgery

20. Plan and time surgery:-
 Factors determining the readiness for surgical repair of
ECF:-
 Physiological-
 Sepsis adequately treated.
 Nutritionally replete/ positive nitrogen balance
 Abdominal Hostility-
 Abdomen soft, clinically no induration
 Granulating wound/ prolapsing bowel loop
 Time since fistula development
 Minimum 6 wks
 Usual time around 6 months
 Psychology
Pt ready and prepared psychologically

21. Strategy for surgery:-
 Indications for Re-laparotomy in the early post-opeartive
period:-
• Generalized peritonitis
• Deterioration despite radiological assisted drainage.
• Multiple or septate collections
• Ischemic bowel
• Abd compartment syndrome
• Inability to protect the skin from intestinal content
 Principles to follow in complicated cases:-
• Construction of stoma proximal to an anastomotic leak or
fistula.
• Peritoneal lavage(toileting)
• Debridement of dead tissue

22.  Resection of fistula and EEA
 Reconstruction of abdominal wall defect:-
 Primary closure
 Component separation technique
 Prosthetic mesh- single stage or vicryl and prolene
based two stage closures
 Biological mesh- decellularised collagen matrices
(allograft / xenograft) or non cross linked porcine
derived mesh
 Emotional and psychological support

23. Hyperventilation
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