1. By : Kinjal Banerjee
SU-6

2. DISCUSSION
INTRODUCTION
Fistula is defined as an abnormal communication between two epithelialized
surfaces.
Enterocutaneous fistula is an abnormal communication between the skin with
various parts of the gut, for example duodenum, jejunum etc.
The word fistula means a “pipe” or “flute” in Latin.
 The ileum is the most common site of origin of Enterocutaneous fistula.

3. Patients are usually systemically ill, with sepsis being a significant risk factor.
Spontaneous closure rate depend upon many factors like anatomy, etiology,
nutritional status, output from fistula.
Fluid and electrolyte imbalance, malnutrition, sepsis & related complications,
local wound excoriation are some of the known complications.

4. ETIOLOGY
Webster and Carey proposed five mechanisms of fistula formation :
1> Congenital : - Rare
- Due to the complete failure of Vitellointestinal duct to obliterate.
- Fecal matter at umbilicus after post natal slough of the stump.
2> Trauma :
- Major penetrating trauma to the abdomen may lead to ECF.
- Damage control laparotomy techniques have higher risk of
delayed ECF formation(2% to 25%).

5. 3> Infection : - Abscess or invasive intestinal infections like amoebiasis,
coccidiomycosis, tuberculosis etc.
- Intestinal perforation in ileum from tuberculosis or enteric fever
esp in 3rd world countries.
- Actinomyces infection post appendectomy.
4> Perforation or Injury with Abscess & Operative complications :
- Intra-abdominal abscess may erode into the gut & through the
skin.
- 75-85% are iatrogenic - after surgery for bowel obstruction,
cancer, or IBD

6. 5> Inflammation, Irradiation or Tumour :
- Crohn’s disease may cause ECF – post op more common
than spontaneous.
- ECF after anastomosis/appendicectomy/simple exploration
in Crohn’s disease.
- Irradiation for pelvic malignancies etc may lead to a chronic
non-healing ECF.

7. PREVENTION OF FISTULA
- Acute intra-operative perforations should be identified and closed.
- Serosal tears should be examined carefully and repaired if required.
- Aggressive interloop adhesion break-up should be avoided to prevent serosal
tears.

8. DIAGNOSIS OF PERFORATION AND FISTULA
-Post operatively anastomotic leaks/unrecognised perforations and
subsequent fistulae may manifest as instability or patient’s failure to improve.
-Fever, abdominal pain followed by exiting of intestinal contents from drain or
incision site.
-Occasionally,heavily purulent discharge may mask an ECF like in enteric
perforations.
-Activated charcoal or indigo carmine by mouth can help in diagnosing ECF.
- Intraluminal instillation of methylene blue and saline or direct endoscopy helps
to identify small perforations.

9. STAGING AND CLASSIFICATION
1. Anatomical Classification : Internal or External fistula(ECF).
- Internal fistulae are named after the structures it communicates
like gastrocolic, jejunoileal, aortoenteric fistula.
- External fistulae like gastric, duodenal, jejunal, ileal or fecal.
2. Physiologic classification : Based on output
- High-output > 500 cc/day (Difficulties in fluid management and
skin care)
- Moderate-output 200-500 cc/day
- Low-output < 200 cc/day (Usually colonic)

10. MANAGEMENT
S-S-N-A-P

Stabilization

Control of Sepsis and appropriate Skin care

Nutrition

Define underlying Anatomy

Plan to deal with the fistula

11. STABILIZATION
> The first step of management is the resuscitation and stabilization of the patient.
> Needs to be accomplished within the first 24 to 48 hours of management.
> Initial efforts directed towards intravenous fluid resuscitation, control of infection,
protection of surrounding skin & measuring and replacing ongoing losses.
> Attention should also be given to any intra-abdominal/subcutaneous abscesses
& if present they should be drained.

12. A. RESUSCITATION
> Restoration of normal circulating blood volume and correction of electrolyte
and acid-base imbalances are a top priority.
>Rehydration usually requires isotonic fluid(NS/RL) until the patient is euvolemic.
> Strict input and output measurements are essential and CVP monitoring
and urinary catheterisation are especially helpful.
> Ongoing fluid losses should be fully replaced and electrolyte imbalances
must be corrected.

13. RESUSCITATION CONTD..
> Enterocutaneous fistulae are usually associated with hypokalemia and
metabolic acidosis, which require correction.
> Electrolyte measurement of the fistula output helps in planning of
replenishment of ongoing losses.
> Urine output should be restored to greater than 0.5mL/kg/hr.
> Requirement of blood transfusion depends upon overall hemodynamic
status, patient’s oxygen carrying capacity and oxygen delivery.

14. B. NUTRITION
> In 1972, Roback and Nicholoff reported closure of 73% of enteric fistulae
in adequately nourished patients, as against 19% in inadequate ones.
> Nutritional support needs to begin as soon as the patient is stabilized.
> Nutrition can be given by parenteral or enteral route,based on the anatomy
of the fistula.
> Its advisable to provide atleast a part of the daily nutritional requirement
through enteral route.(Even 25% of daily requirement given enterally,
can help reap its benefits)

15. NUTRITION CONTD..
> Nutrition via the enteral route helps in maintaining the intestinal mucosal
barrier, more efficacious delivery of nutrients, stimulating hepatic protein
synthesis.
> WHO’s ORS (40g/L of glucose, 90 mEq/L of Na, 20 mEq/L of K) should be
given when oral intake is possible.
> In proximal fistulae, the enteral feeding tube may be entered beyond the
fistula to provide enteral nutrition(fistuloclysis).
> It is advisable to enter feeding tube beyond ligament of Treitz for a gastric
or duodenal fistula.

16. NUTRITION CONTD..
> Enteral feeds of highly absorbable, low-residue nutrients can be given if even
4ft of functional bowel exists in between ligament of Treitz and the proximal
end of the fistula.
> During the time the enteral nutrition is increasing, patient should be
supplemented with TPN.
> TPN is also given in patients who do not tolerate enteral feeds or have
long standing ileus or before fistulous tract is well established.

17. NUTRITION CONTD..
TYPE OF FISTULA
CALORIE REQ
PROTEIN REQ
Low Output
30-35 kcal/kg/day
1-2 gm/kg/day
High Output
45-50 kcal/kg/day
1.5-2.5 gm/kg/day
> Twice the daily requirement of vitamins, trace elements, zinc and upto 10 times
the daily requirement of Vitamin C should be provided.
> Short turnover proteins like retinol-binding protein, prealbumin, ferritin can be
used to monitor the weekly efficacy of protein delivery. [Alb half life is 20 days].
> Mortality rate of 42% with alb <2.5 mg/dl vs 0% if >3.5 mg/dl.

18. C. CONTROL OF SEPSIS AND FISTULA EFFLUENT
> Persistant fever, tachycardia and leukocytosis along with failure to improve
adequately points towards possible sepsis or abscesses.
> May require surgical drainage of abscess,if any along with adequate antibiotic
cover.
> Local skin care and prevention of skin excoriation by using stomahesive paste
or aluminium paint etc along with stoma bags.
> Excessive fistula output can be controlled by nasogastric tube placement,
withdrawal of oral feeds, initiation of parenteral nutrition or placement of
sump suction catheter as described by Suripaya and Anderson,1971.

19. C. CONTROL OF SEPSIS AND FISTULA EFFLUENT CONTD..
> Vacuum assisted closure [VAC] device drainage system maybe used too.
> Due to the negative pressure application, VAC device helps to control drainage,
minimizes the size of the abdominal wound, reduces frequency of dressing
and protects the skin while helping to promote fistula healing.
> For majority of ECFs, VAC devices have become the method of choice for
controlling fistula drainage and skin protection.

21. D. PHARMACOLOGICAL SUPPORT
> Somatostatin analogue Octreotide, at doses of 100 – 250 mcg TDS reduces
fistula output by 40 – 60% by the end of 24 hrs.
> Should be discontinued if ineffective for 48 hrs as it has side effects like
hyperglycemia, elevated cholesterol and reduced bowel motility.
> Octreotide and TPN seem to have a synergistic effect on reduction of effluent
volume and improvement in fistula closure rates.
> Proton-pump inhibitors and H2 receptor antagonists also help reduce fistula
output especially in proximal fistulas.

22. D. PHARMACOLOGICAL SUPPORT CONTD..
> Cyclosporine in doses of 4 mg/kg/day for 6 – 10 days followed by oral doses
of 8 mg/kg/day helps to treat refractory fistulae associated with Crohn’s disease.
> Other drugs used include Tacrolimus, Azathioprine, 6-MP, Infliximab(mAb TNFα).
> Infliximab administered at a dose of 5 mg/kg iv at 0,2,6 weeks helped in partial
resolution of 68% of multiple lesions and complete closure in 55% of patients.
> Complications include URTI, headache, fatigue etc.

23. INVESTIGATIONS
> Investigations are done for the next 7 to 10 days following stabilization.
> They are carried out to determine the presence and location of the fistula,
its cause and presence of comorbidities.
> Oral administration of Indigo Carmine/ Charcoal helps in diagnosing the
presence of a fistula,but not its location, cause or anatomy.
> USG abdomen helps in locating intra-abdominal abscesses, apart from
helping in performing guided aspiration of intra-abdominal collections.

24. > Fistulography helps in defining the length & width of the fistula, its anatomical
location, the presence of any distal obstructions etc.
> It can be performed by entering a small cathter into the fistulous tract and then
injecting the water-soluble contrast under fluoroscopy.
> Fistulogram should be performed before an upper GI series or CT scan with
oral contrast or contrast enema as it poses difficulty in interpretation.
> Fistulography should be followed up with a complete contrast study of the
GI tract.

26. CT scan of the abdomen with IV and oral contrast is highly sensitive and specific
for locating the fistula, defining its anatomy, commenting on the gut surrounding
fistula, presence of any intra-abdominal abscess or distal obstruction/pathology.
CT scan is highly recommended for duodenal and pancreatic fistula.
CT scan can be therapeutic by helping in CT-guided aspiration of intra-abdominal
abscesses,if any.
Endoscopy may also be used occasionally though its principal use is in internal
fistulas.
Endoscopy is usually delayed till acute inflammation gets reduced.

27. DECISION
FACTORS RESPONSIBLE FOR SPONTANEOUS CLOSURE
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
Referred from outside
institution
Original operation at same
institution

28. > Reber et al reported that more than 90% of small intestinal fistula which
closed spontaneously,did so within a month.
> Spontaneous closure rates dropped to less than 10% after 2 months and
none after 3 months.
> Factors possibly responsible for failure of spontaneous closure are:
a. Foreign Body
b. Radiation
c. Inflammation/ infection
d. Epithelialisation
[F-R-I-E-N-D-S]
e. Neoplasm
f. Distal intestinal obstruction
g. Steroids.

29. DEFINITIVE THERAPY
> Majority (80-90%) will close within 6 weeks with conservative management.
> Surgery between 10 days and 6 weeks post-op will encounter the worst
adhesions.
> Preferably wait upto 6 weeks before open exploration and repair of defect,
but in case of faecal fistula, due to intense inflammation, it is prudent to wait
upto 10-12 weeks.
> The patient should,by then, be nutritionally optimized, patient should not be septic
and patient should be vitally stable.

30. > Definitive operative correction remains the final step in the treatment of
non-healing small intestinal fistulas.
> In majority of the cases, preferred operation is resection of the involved segment
with primary end-to-end anastomosis. (Reber HA, 1978)
> However if primary anastomosis is not possible,then both the proximal and
distal ends of intestine are exteriorized.
> In case the fistula is deemed inappropriate for resection, such as when it
develops after a deep pelvic procedure, staged approach involving bypass
should be considered.

31. > In a staged procedure, the fistulous segment is left in-situ or the ends are
exteriorized as mucous fistula and the afferent and efferent bowel loops
are anastomosed to restore intestinal continuity.
> The staged procedure is completed when the fistula segment is removed at
a later date,although it may not always be possible.
> Enteroatmospheric fistulas, which are associated with large abdominal defects
are very difficult to manage and are associated with high mortality rates.
> Mortality rates may vary from 20% to 60%. (Schein M, Decker GA 1991)
> Enteroatmospheric fistulas usually require multiple staged operations.

32. ENTEROATMOSPHERIC FISTULA

33. > Enterocutaneous fistula treatment is complicated due to various factors like
open abdominal wound leading to desiccation of gut loops, presence of
multiple fistulous openings, dressings adhering to the gut loops etc.
> VAC devices are used initially to approximate the large abdominal defect
along with isolation of the fistula(s) by ostomy bags.
> After proper granulation tissue formation, the stabilized patient can be
considered for SSG, if his nutritional status is favourable.
> After 6 to 12 months recovery time to replenish protein and calorie stores,
resection of the fistula as definitive therapy can be provided to the patient.
> Musculocutaneous flaps, abdominal wall reconstruction by component
separation technique, use of prosthetic materials,esp biologics may also
be necessary. (human acellular dermal matrix)

35. > In 1995, Ho HS and Frey CF used primary closure of gastric fistula with
delayed external drainage as treatment for gastric fistulas.
> If the gastric fistula defect is too large to allow primary closure,then a
Roux-en-Y gastrojejunostomy may be done.
> Duodenal fistulas are usually treated with tube duodenostomy or Roux-en-Y
duodenojejunostomy.
> A feeding jejunostomy distal to the enteroenterostomy should always be
considered.

37. Roux-en-Y Duodenojejunostomy

38. CONCLUSION
> Enterocutaneous fistulas are abnormal communication between the gut
and skin.
> Majority of the ECF are due to iatrogenic causes (70-85%). Others include
trauma, congenital causes. Spontaneous ECF may arise due to Crohn’s
disease.
> Malnutrition, Electrolyte imbalances, acid-base imbalances and sepsis are
the major causes of mortality in ECF.
> After initial stabilization of the patient by resuscitation( fluid, electrolytes,
blood transfusions etc), the patient is subjected to various investigations
to determine the location& anatomy of fistula, presence of distal obstruction
etc.

39. > Enteral nutrition is always preferable to parenteral nutrition provided the
patient tolerates enteral feeds.
> Local wound care by application of ostomy bag and pastes are essential.
> Drainage of intra-abdominal abscesses, treatment of sepsis is of utmost
importance.
> After proper optimization, patient undergoes definitive therapy which
includes resection of the fistulous segment of the gut.
> ECF with large abdominal defects may require VAC devices/ biologic mesh
SSG to help close the defect.

40. THANK YOU