ENTEROCUTANEOUS FISTULAE

PATHOPHYSIOLOGY

SOETAMTO WIBOWO
DEPT OF SURGERY AIRLANGGA UNIVERSITY
DR. SOETOMO GENERAL HOSPITAL - SURABAYA
GOOD 4 U
ENTEROCUTANEOUS
FISTULAE

SURGEONS ERROR ?
MAL PRACTICE !

CATASTROPHE
PATIENTS FAMILY
DOCTORS NURSES
HOSPITAL
ENTEROCUTANEUS FISTULAE
FISTULA : AN ABNORMAL COMMUNICATION
BETWEEN TWO OR MORE SURFACE OF
EPITHELIUM

ETHIOLOGY (HISTORY)
1945 : SPONTANEOUS - HIGH MORTALITY
1945 -1970 : POST OPERATIVE COMPLICATION
(1968) : PARENTERAL NUTRITION
LOCAL FISTULAE CONTROL
COMBAT SEPSIS
1980 - : MORE AGGRESSIVE OPERATIVE
PROCEDURE

RINSEMA : PROEFSCHRIFT RYKS UNIVERSITEIT

MAASTRICHT 1992
 EXTERNAL
ENTEROCUTANEOUS FISTULAE
RECTOVAGINAL
ENTERAL FISTULAE

INTERNAL
ENTERO ENTERAL
ENTERO VESICAL

RINSEMA (HOLLAND) AUTHOR (SURABAYA)

(1977 1987) (2002 2003)
EXTERNAL FISTULAE 106 (77%) 22 (88%)

INTERNAL FISTULAE 32 (23%) 3 (12%)

TOTAL 138 25
ENTEROCUTANEOUS FISTULAE

DIRECT FISTULAE = SIMPLE FISTULAE

INDIRECT FISTULAE = COMPLICATED FISTULAE

DIRECT FISTULAE INDIRECT FISTULAE

 DIRECT FISTULAE

INDIRECT FISTULAE
 ENTEROCUTANEOUS FISTULAE
2002 2003

MALE FEMALE TOTAL

n 18 7 25

MEAN AGE 38.4 19.07 36.88 10.97

(YRS)
SURGICAL COMPLICATION AS CAUSE OF FISTULAE FORMATION

RINSEMA (HOLLAND) AUTHOR (SURABAYA)

1977 1987 2002 2003

63/96 (66%) 19/25 (76%)

 POST OPERATIVE ENTEROCUTANEOUS
FISTULAE

RINSEMA (HOLLAND) AUTHOR (SURABAYA)

1977 1987 2002 2003
n = 66 n = 19
SUTURE LINE FAILURE 27 (41%) 12 (63%)

SECONDARY FAILURE 39 (59%) 7 (37%)

PRIMARY CAUSE OF ENTROCUTANEOUS FISTULAE

AUTHOR (SURABAYA) LEVY (PARIS)

2002 2003 1976 1986
n % n %
MALIGNANCY 8 (32%) 45 (21.43%)

APPENDICITIS 4 (16%) 27 (12.86%)

ADHESION 4 (16%) 43 (20.48%)

TRAUMA 3 (12%) 13 (6.19%)

IBD (CROHN) 2 (8%) 33 (15.71%)

DIVERTICULITIS 1 (4%) 27 (12.86%)

INCARCERATED HERNIA 1 (4%) 9 (4.29%)

RADIATION INJURY 1 (4%) 13 (6.19%)

DELIVERY INJURY 1 (4%) -

 LOCATION OF G.I. FISTULAE

LOCATION n %
COLORECTAL 10 (40%)
ILEUM 8 (32%)
APPENDIX 5 (20%)
GASTER 1 (4%)
JEJUNUM 1 (4%)
ENTEROCUTANEUS
FISTULAE

HIGH OUTPUT 8
LOW OUTPUT 17
ENTEROCUTANEOUS
FISTULAE

DIAGNOSTIC :

CONTRAST IMAGING
CT SCAN
 FISTULA CLOSED (6)
SURGERY (6)
FISTULA OPEN (-)
LOW OUTPUT
FISTULA E (17)
FISTULA CLOSED (4)
CONSERVATIVE (11)
FISTULA OPEN (4)

FISTULA CLOSED (4)

SURGERY (5)
FISTULA OPEN (1)
HIGH OUTPUT
FISTULAE (8)
FISTULA CLOSED (1)
CONSERVATIVE (3)
FISTULA OPEN (2)
 FACTOR INFLUENCING G.I. HEALING

LOCAL SYSTEMIC
ADEQUAT BLOOD SUPPLY PATIENT NUTRITION
ABSENCE OF ANASTOMOTIC SEPSIS
TENSION
HEALTHY TISSUE EDGES HYPOVOLEMIA
BACTERIAL CONTAMINATION MEDICATION (E.Q. STEROID)
DISTAL OBSTRUCTION IMMUNO COMPETENCE
RADIATION INJURY BLOOD TRANSFUSION
BOWEL PREPARATION UREMIA
HYPERTHERMIA JAUNDICE

THORNTON, SCNA 1997; 77: 549 - 565

 FACTORS THAT PREVENT HEALING OF
INTESTINAL FISTULAE

DISTAL OBSTRUCTION
MALIGNANCY
FOREIGN BODY
ASSOCIATED UNDRAINED INFECTION
RADIATION INJURY TO TISSUE
UNDERLYING INFLAMMATORY CONDITION
(E.Q. CROHNS DISEASES, TUBERCULOSA)

HODIN, SURGERY BASIC AND CLINICAL EVIDENCE

2001, PG. 631
 INCIDENCE OF SEVERITY FACTOR OF
INTESTINAL FISTULAE

MULTIPLE FISTULAE
INTRA ABDOMINAL ABSCESSES
SEPTICAEMIA
ILEUS
ACUTE RESPIRATORY DISTRESS
UPPER GASTRO INTESTINAL TRACT FAILURE
RENAL AND / OR HEPATIC FAILURE
THROMBO EMBOLIC COMPLICATION

Levy, BrJS 1990;70:450 - 463

 CAUSES OF COMPLICATIONS FOLLOWING SURGERY
(BASED ON 1900 COMPLICATIONS IN A SERIES OF
30.000 OPERATIONS)

CAUSES PERCENTAGE OF MORTALITY

ALL COMPLICATIONS %
TECHNICAL OR JUDGEMENTAL 49.0 8.2
ERROR
INHERENT RISK OF CORRECTLY 30.5 31.2
PERFORMED OPERATION
PROGRESS OF DISEASE 15.4 90.8
UNPREDICTABLE COINCIDENCE 3.6 50.0
DIFFICIENT EQUIPMENT OR 0.7 0
PERSONNEL

McGuire, 1990
CONCLUSIONS

IMPROVE TECHNICAL SKILL AND

MANAGEMENT FOR PREVENTING
FISTULA FORMATION
DIAGNOSTIC OF DISEASE AND CAUSE OF
FISTULA
ABOVE ALL, A HIGH LEVEL OF PATIENCE
FOR BOTH THE PATIENT AND THE
SURGEON