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ENTEROCUTANEOUS
FISTULA
OUTLINE
INTRODUCTION
PHYSIOLOGY
PATHOPHYSIOLOGY
CLINICAL FEATURES
PRINCIPLES OF MANAGEMENT
PROGNOSTIC FACTORS
PREVENTION
COMPLICATIONS
CONCLUSION
INTRODUCTION
A fistula is an abnormal communication
between two epithelial-lined surfaces
Enterocutaneous fistula: btw intestine and
skin
Historical aspects[4]:
Antibiotic era 1945-60
Intensive care 1960-70
TPN era 1970-75
CLASSIFICATION
High & Low - obsolete[4]
Types: NEW CLASSIFICATION Siteges-Sera et al modified by
Schein et al
CLASSIFICATION
ANATOMICAL CLASSIFICATION:
CLASSIFICATION
1.
a. Simple or direct.
b. Complicated 1.Having multiple tracts
2. Connection with more than one viscus
3. drainage into an associated abscess cavity.
AETIOPATHOLOGICAL
Congenital
Umbilical fistula.
Acquired
TRAUMA
BLUNT
PENETRATING.
POST-OPERATIVE: 80%
ANASTOMOTIC LEAK
UNRECOGNISED BOWEL INJURY.
SURGERIES LIKELY TO LEAD TO THIS:
ADHESIOLYSIS
SUTURE OF PERFORATIONS
ANASTOMOSIS
SPONTANEOUS:
NEOPLASTICMALIGNANCY
INFLAMMATORY:
TB
DIVERTICULAR DISEASE
CROHNS DISEASE
RADIATION ENTEROPATHY
AMOEBIASIS.
CONTRIBUTING FACTORS
Malnutrition
Sepsis
Hypotension/Shock
Vasopressors
Steroids
Radiotherapy
Anastomotic factors
PHYSIOLOGY
Digestion/ absorption
Water / Electrolyte absorption and
secretion
Carbohydrate digestion/ absorption
Protein digestion/ absorption
Fat digestion / absorption
Vitamin/ mineral absorption
Barrier / immune function
Motility
Endocrine function
PATHOPHYSIOLOGY
Depends on structure involved
Loss of GI Content
Hypovolaemia, Acid-base and electrolyte
abnormalities, Malnutrition.
Sepsis
Intra-abdominal sepsis
Wound infection
Septicaemia
3). Malnutrition
- Reduced oral intake
- Hypercatabolism
- Loss of nutrients
- Loss of digestive juices
- Insufficient absorptive surface
Natural history
Likely to
close
Unlikely to close
Anatomic
location
Esophageal,
Duodenal
stump, jejunal
Gastric,ileal
Nutritional
status
Sepsis
Present
Etiology
Appendicitis,
diverticulitis
post operative
Crohns, cancer,
foreign body,
radiation
CLINICAL PRESENTATION
POST OPERATIVE FISTULA
Recognized 5th-10th days Abdominal tenderness
post operatively.
Fever
Leucocytosis
Prolonged ileus
Drainage of enteric
material through the
abdominal wound or
through or existing
drains.
Localized swelling
of the abdominal
wall.
Point tenderness.
May be
Hypotension
dehydration
CLINICAL PRESENTATION
SPONTANEOUS FISTULA:
INDOLENT MANNER.
FEATURES OF UNDERLYING DISEASE.
INTERNAL FISTULA PNEUMATURIA, FAECOLURIA.,
DIARRHOEA, VAGUE ABD PAIN.
PRINCIPLES OF MANAGEMENT
AIM
To restore bowel integrity and continuity
3 Stages of care
Acute
Sub acute
Definitive Repair
Stoma Nurse/Therapist
Dietician
TPN team
Psychologist/Social work
PRINCIPLES OF MANAGEMENT
S Stabilization,Sepsis control, Skin/stoma care
N Nutrition
A Anatomical Assessment/definition
P Planned definitive procedure
Principles of Management
Fluid Resuscitation and Electrolyte
Sepsis Control
Peritonitis/Drainage/Antibiotics/ Wound Care
Acute Surgery
Acute intervention is necessary in
Generalised peritonitis
Cellulitis/ necrotising fasciitis
Collections not amenable to perc drainage
Complete disruption of an anastomosis
Removal of foreign body e.g. mesh
Feeding gastrostomy/jejunostomy
Fistula Output
Replace losses with saline
Rehydrate with electrolytes/glucose
Medication
Antisecretory
PPIs
Somatostatin/Octreotide
Antimotility
Loperamide/lomotil
Codeine
NUTRITION
Malnutrition predicts both mortality and
failure of repair
Multifactorial cause for malnutrition
Nutrition Approaches
TPN
Significant contributor to improved mortality
Bowel rest and spontaneous closure
May be only viable option
Enteral
Advantage for SBP, GIT function,
anastomosis
Elemental feeds
Oral, NGT / fistuloclysis / feeding ostomy /
reinfusion
Manage deficiencies
Give adequate calories
ANATOMICAL DEFINITION
Delineate tract
Origin
Path
Length, Width
Define extent of bowel wall disruption
Exclude distal obstruction
Identify Collections
Etiological disease process
CT
Fistulogram
Oral and PR contrast
MRI
Ba enema
Endoscopy
Long incision
Upper abdo usu fewer
adhesions
Complete, careful
adhesiolysis
Hydro dissection
technique
Experienced assistant
Repair any serosal tear
or enterotomy as they
occur
SURGICAL TREATMENT
- Preferred op is resection of fistulous segment
and tract with end-to-end anastomosis
- Dissection should be minimal and
preferably sharp[4]
- Omental patch, proximal colostomy or
ileostomy optional
PROGNOSTIC FACTORS
PREDICTORS OF SPONTANEOUS
CLOSURE & MORTALITY
Serum levels of short turnover proteins
A. Albumin
B. Retinol binding pre-albumin
C. Thyroxin binding pre-albumin
D. Serum transferrin
[4]
Predictors of
mortality
REHABILITATION
Continued nutrition support
Zn supplementation
Psychological/ occupational therapy
PREVENTION
[3]
COMPLICATIONS
[3]
Anastomotic stricture
DVT
Adhesive small bowel obstruction
Short bowel syndrome
Recurrence
LITERATURE REVIEW
[3]
Morbidity 80%
Success @ 1st attempt 70%
Overall closure rate 84%
CONCLUSION
[4]
Reference
1. Atlas of Intestinal Stomas 2012
2. Schwartz Principles of Surgery 10 th Ed
2014
3. Maingots Abdominal Operations 11th Ed.
4. Ajao OG, Shehri MY. Enterocutaneous
fistula. Saudi J Gastroenterol [serial
online] 2001 [cited 2011 Jul 22];7:51-4.
Available from:
http://www.saudijgastro.com/text.asp?200
1/7/2/51/33401