This document provides an overview of enterocutaneous fistulas (ECF), including their definition, classification, clinical presentation, investigation, and treatment. ECFs are abnormal connections between the gastrointestinal tract and skin/wound. They are usually classified based on output, etiology, and source. Treatment involves stabilization, control of sepsis, nutrition support, defining anatomy, and planning surgical or non-surgical management. Conservative treatment is preferred initially through wound care, nutrition, and controlling output/sepsis, while surgery is considered if conservative measures fail or timelines are exceeded.

1. MANAGEMENT OF ENTEROCUTANOUS FISTULA
BY
DR. BARIBOTE O. S.
MBBS – NDU
30th OCTOBER, 2020
DEPARTMENT OF SURGERY
NDUTH

2. Outline
Introduction
History of ECF
Epidemiology
Classification
Clinical presentation
Investigation
Treatment
Conclusion

3. Introduction
Definition
• A fistula is an abnormal connection between two epithelized surfaces
Anatomical subdivisions:
• Internal and External
Internal fistulas are connections between two internal structures.
Examples:
External fistulas form connections between an internal structure and external
structure.

4. Introduction contd
An enterocutaneous fistula (ECF) is an aberrant connection between the
intra-abdominal gastrointestinal (GI) tract and skin/wound.
Conventionally, ECF is limited to those arising from the
• duodenum,
• jejunum,
• ileum,
• colon or
• rectum
although it can occur in the stomach, oesophagus and anus

5. History of ECF in medicine
Treatment of ECF continues to be a difficult task
• He stated “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”
Celcus in 53 BC
• He expressed this “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”
John Hunter

6. Epidemiology
Enterocutaneous fistula mortality rates vary from 6% to 33%.
Incidence is dependent on etiology.
Infected pancreatic necrosis
• extremely high incidence of 50%.
Trauma patients
• 2% to 25% incidence,
and abdominal sepsis
• 20% to 25% incidence.

7. Classification
• output,
• etiology,
• and source
There are several ways in which ECF has
been classified, including
• high-output ECF - >500 mL/24 hours,
• moderate output 200 - 500 mL/24 hours
• low output <200 mL/24 hours,
According to Output:

8. According to etiology
• 75-85% are iatrogenic
• Typically after surgery for bowel obstruction, cancer, or IBD
• 15 -25% result from abdominal trauma or spontaneously
Berry SM, Fischer JE
• Postoperative
• Traumatic
• Spontaneous
Etiology Characterized as

9. Postoperative
Disruption of anastomosis
Inadvertent enterotomy
Inadvertent small bowel injury

10. According to etiology contd
Traumatic causes
• Iatrogenic surgical trauma to the bowel that may or may not be
recognized
• Road traffic accidents with injury to the gut
Spontaneous causes
• Malignancy
• Radiation enteritis with perforation
• Intra-abdominal sepsis
• Inflammatory bowel disease
• Crohn disease
• Ulcerative colitis

12. According to source
type I
type II
type III
type IV
• esophageal,
gastroduodenal,
• small bowel,
• large bowel and
• enteroatmospheric,
regardless of origin

14. Clinical presentation
• Postoperative abdominal pain
• Tenderness
• Distension,
• Enteric contents from the drain site and the main abdominal wound
• Tachycardia and pyrexia
Features suggestive of an ECF include
• Guarding, rigidity and rebound tenderness
Signs of localized or diffuse peritonitis
• Sepsis
• Fluid and electrolyte abnormalities
• Malnutrition
Signs of complication might be present

15. Investigation
Laboratory
investigations
Full blood
count +
differential
• Sepsis
• Anaemia
E/U/Cr
• Electrolyte
abnormailies
Total
proteins,
serum
albumin and
globulin
Serum
transferrin –
Low levels
(<200mg/dl)
are a
predictor of
poor healing

16. Imaging studies
Fistulography
• Contrast media such barium sulphate is injected into the fistulous
tract
• Conventionally performed 7-10 days
It provides
• Length of the tract
• Extent of the bowel wall disruption
• Location of the fistula
• Presence of a distal obstruction

19. Imaging contd
• Useful in patients with ECF involving the colon especially those
due to failure of low colorectal anastomosis
Water soluble contrast enema
• Class I: Simple, short blind ending < 2cm
• Class II: Continuous linear, long simple, >2cm
• Class III: Continuous complex, multiple linear
The following tracts can be seen
• Anterior – ventral 10 to 2 0’clock position
• Posterior – dorsal 4 to 8 0’clock position
• Lateral – right (2 to 4 0’clock) or left (8 to 10 0’clock)
Tracts positions are as follows

20. CT scanning and USS
•Useful in demonstrating intra-abdominal abscess cavities
Markers
•Oral administration of nonabsorbable marker eg
charcoal, congo red – help confirm the presence of ECF
•Beside administration of methylene blue diluted in
saline via NG tube can be used to confirm presence of
ECF especially those with gastrocutaneous fistula or
lateral duodenal fistula

21. Predictive factors for spontaneous closure and/or
mortality
Factor Favorable Unfavorable
Organ of origin Esophageal, Duodenal stump, Pancreatic,
Biliary, Jejunal, Colonic
Gastric, Lateral duodenal, Ligament of
Treitz, Ileal
Etiology Postop (anast leak), Appendicitis, Diverticulitis Malignancy, IBD
Output Low (<200-500cc/day) High (>500cc/day)
Nutritional status Well nourished, Transferrin >200 Malnourished, Transferrin <200
Sepsis Absent Present
State of bowel Intestinal continuity, absence of obstruction Diseased adjacent bowel, Distal
obstruction, Abscess, Discontinuity,
Irradiation
Fistula characteristics Tract >2 cm, Defect >1cm Tract <1cm, Defect >1cm
Miscellaneous Original operation at same institution Referred from outside institution
21

22. Treatment
Conservative
Surgical

23. • Rehydration
• Administration of antibiotics
• Correction of anemia
• Electrolyte repletion
• Drainage of obvious abscess
• Nutritional support
• Control of fistula drainage
• Skin protection
The principles of nonsurgical therapy for
ECFs include the following:

24. •S – Stabilization
•S – Control of sepsis and skin care
•N – Nutrition
•A – Defining of anatomy
•P – plan to deal with the fistula
The common acronym used in the
management is S-SNAP

25. Treatment
Resuscitation and stabilization
• 24 to 48 hours
Priorities:
• Normal circulating blood volume
• Correction of electrolyte and acid-base imbalances
Rehydration usually requires isotonic fluid (NS/RL) until the patient
is euvolemic
Strict input and output measurements are essential

26. Patient should be catheterized and urine output maintained at 0.5ml/kg/hr
Common problems include
• Dehydration
• Hyponatremia
• Hypokalemia
• Metabolic acidosis
Electrolyte measurement of the fistula output helps in planning of
replenishment of ongoing losses

27. Control of sepsis
Sepsis is responsible for 77% of mortality associated with ECF
CT or USS of the abdomen and pelvis along with percutaneous
drainage with radiographic guidance is essential to evaluate and
treat sources of infection
In cases of peritonitis and without the ability to obtain source
control with more conservative means,
• prompt fluid resuscitation,
• antibiotic administration, and
• operative control of infection are essential.

28. Control of sepsis contd
• infection drainage and
• exteriorization of the source in the small or large intestine,
Operative sepsis control should focus on
• in a critically ill patient or
• in the setting of significant purulence or fecal
contamination
No anastomoses

29. Nutrition
Nutrition is one of three necessities upon which the life and successful
treatment of a patient with ECF hinges
Fazio et al showed that mortality is 0% when serum albumin is > 3.5 mg/dL
Fistula closure rates are twice as high in those receiving adequate
supplemental nutrition as opposed to those who are not.
The goal of successful nutrition management is achieving
• an anabolic state with weight gain,
• improvement in albumin,
• prealbumin, and transferrin, and
• successful management of micronutrient needs for optimal healing

30. inadequate
calorie intake,
catabolism
due to
sepsis,
ongoing GI
losses
Sources of
malnutrition

31. Feeding
• Main stay of nutrition in ECFs
• Distal ileum
• Colon or
• Duodenum
• Elemental diets
Enteral
feeding
• Gastric fistula
• Duodenal
• Small bowel fistula
• High output fistula
Total
Parenteral
feeding

32. Routes of Enteral feeding
• Oral
• Feeding jejunostomy
• Nasogastric tubes
• Nasojejunal tubes
• Gastrostomy
Studies have shown that the provision of only 20%
of calories fed enterally protect the integrity of
mucosal barrier, as well as the immunologic and
hormonal function of the gut

33. Fistuloclysis

35. Nutrition needs of patient with ECF
Calorie
requiremen
t(kcal/kg/d)
Protein
requirement
(g/kg/d) Vitamin C
Other
vitamins
Elements
(zinc,
copper,
selenium)
Low-output
fistula
20–30 1–1.5 5–10 times
normal
At least
normal
At least
normal
High-output
fistula
25–35 1.5–2.5 10 times
normal
2 times
normal
2 times
trace
elements

36. • 75g glucose
• 20g amino acids
• 30 g lipids per 1000ml
A standard general purpose formula for TPN consists of
the following:
Monitoring of level of nutrition is essentially
• albumin,
• prealbumin,
• weights,
• and transferrin
One measure of tracking success weekly is checking
• triceps skin fold thickness (approximates body fat reserves) and
• midarm muscle circumference (approximates muscle mass)
In addition, anthropometric assessment based on

37. • For high output fistula, use of a pouch to collect the
effluent is preferred
• For a low output fistula, a skin barrier with
dressing/pouch is advocated
Skin care
• Restrict hypo-osmolar fluids
• Anti secretory agents
• Antimotility agents
Methods of reducing fistula output

38. Surgical intervention
• Foreign body
• Radiation
• Inflammation, Infection
• Epithelialization
• Neoplasm
• Distal obstruction
• High output fistula
• Low serum transferrin (<200mg/dl)
In the face of unfavorable factors that prevent spontaneous
closure:
• Fistulas from esophagus to duodenum: 2~4 weeks.
• Colonic fistulas: 30~40 days.
• Small bowel fistulas: 40~60 days.
Exceeding of expected time period for spontaneous closure:

39. Definitive repair of the ECF should be planned if no
spontaneous closure occurs by 12 weeks after
• sepsis control,
• nutritional optimization,
• and establishing wound cares.
Pre-operation preparation includes
• intra-luminal antibiotics,
• mechanical bowel preparation,
• discontinuation of enteral nutrition,
• meticulous skin care,
• control fistula drainage

40. Intraoperative details
Skin incision
• Fresh skin incision
• since there is a possibility of the gut being adherent to the site of the incision of
the index operation
Once the peritoneal cavity is assessed, the entire bowel is made free of all adhesions
Fistulous site is dissected free from the surrounding structures and excised
Restoration of bowel continuity should be done with a
• double layered anastomosis
• involving a healthy and well vascularized bowel segment
If the patient is sick and cannot withstand a resectional procedure,
• exteriorized via ileostomy or colostomy

41. Non operative therapies
• An ideal fistula for treatment wound be long, narrow, low output, devoid of
distal obstruction and IBD
Fibrin Sealant
• Endoscopic clip technology is available for acute fistulas and perforations
and is not well suited to chronic ECF
Endoscopic Clips
• Gelfoam embolization
Others include

42. Conclusion
• ECF remains a complex problem that is optimally management using a
careful and interdisciplinary approach.
• In addition to primary management of sepsis,
• conservative treatment remains the treatment mainstay,
• including the combination of wound management,
• nutritional support with EN or PN sometimes in combination, and
social support.
• Surgical treatment with resection should be carefully planned and is
used in cases that fail conservative treatment.

43. Reference
• Sitges-Serra A, Jaurrieta E, Sitges-Creus A. Management of
postoperative enterocutaneous fistulas: the roles of parenteral
nutrition and surgery. Br J Surg. 1982;69(3):147–150.
• Schein M, Decker G A. Postoperative external alimentary tract
fistulas. Am J Surg. 1991;161(4):435–438
• Berry S M, Fischer J E. Classification and pathophysiology of
enterocutaneous fistulas. SurgClin North Am. 1996;76(5):1009–1018.
• Lloyd D A, Gabe S M, Windsor A C. Nutrition and management of
enterocutaneous fistula. Br J Surg.2006;93(9):1045–1055.