UPDATES IN

MANAGEMENT OF
ENTEROCUTANEOUS
FISTULA
BY DR BASHIRU A
 OUTLINE

Introduction
Definition
Classification
Aetiology
Pathophysiology
Management Protocol
Prevention
Conclusion
Introduction

 A big challenge to the surgeon despite advances in

surgical technique and advent of minimal access surgery
 Three quarters have remained post surgical
 Two thirds have persistently involved small bowel
 Most occur in the setting of surgery on diseased bowel,
overwhelming sepsis, HIV, and malnutrition
 Significance lies in the incidence of these factors
associated with large numbers of our patients
 It becomes more ominous when we consider that many
present late with financial challenges
 Even more difficult in centers with little or no MDT
Definition

 A fistula is a communication btw two epithelial surfaces

lined by granulation tissue
 Enterocutaneous fistula is an abnormal communication
between bowel & the skin. It is also called external
intestinal fistula
 The track as mentioned is usually formed by granulation
tissue but in some cases may be lined by epithelium
 Connotes poor likelihood of closure
Classification
• INTERNAL-communication between 2 or more hollow viscera, without external
communication
• EXTERNAL(ENTEROCUTANEOUS)-when a hollow viscus discharges to body surface
• MIXED-when both components are present
• SIMPLE-single direct track
• COMPLICATED/-multiple tracks or an assoc abscess cavity
• LATERAL-arising from side of a hollow viscus
• END FISTULA-arising from whole circumference of the involved bowel & there is no
further continuity of the gut
• *Enteroatmospheric
 Classification
 VOLUME OF OUTPUT-
High output- >500ml/24hrs- mortality of 50% levi et al, (less likely to close campos et
al)
Moderate Output- 200-500ml/24hrs

Low output- <200ml/24hrs-mortality of 22% levi et al(more likely to close campos et

al) )
*Reviewed in view of nature of pancreatic & hepatobilliary fistulae

ANATOMIC SITE-Proximal & distal

Nature of track- Simple or Complicated
 Relationship to circumference- End fistula or lateral fistula
 *CLASSIFICATION-
location/mortality
Proposed by Siteges-Sera et al & modified by Schein et al as follows

TYPE MORTALITY RATE

I.Abdominal oesophagus + gastroduodenal fistulae

17%

II.Small
bowel fistulae 33% *(mortality range for different
countries is 12-33%)

III.Large bowel fistulae 20%

IV.Fistula at any site with assoc large abd. Wall defect

60%
AETIOLOGY

 Esophageal fistula usually occur in setting of resection

for malignant disease
 Gastric fistula occur following gastrostomy usually in
children for more than 9 months
 Duodenal follow gastric or hepatobiliry/ pancreatic
resections
 Appendiceal follow drainage if abcess and the fistula is
in terminal ileum not cecal
 Small bowel is most common and usually post operative
 Colonic follows resection and anastomosis in deseased
bowel or anastomotic leaks usually
 AETIOLOGY
 SURGERY-(has remained the commonest cause)
 usually due to unrecognised injury to bowel or due to breakdown of anastomosis
 *Time frame for surgery in adhesions
 TRAUMA- Blunt or Penetrating(on the rise 2nd to militancy, armed conflict, small
arms proliferation)

 SPONTANEOUS EXTENSION of intrabdominal dx thru the abd wall from late

presentation e.g

I. Sloughing of a strangulated hernia

II. Pointing of an empyema of the gallbladder

III. Duodenal ulcers eroding thru abd. wall

AETIOLOGY CONT

 **INFLAMATORY CONDITIONS such as TB which is still

common despite efforts by involved agencies and
advent of HIV
 **diverticular dx, chron’s dx which we ere not
diagnosing before but are common now
 OTHERS
 RADIATION ENTERITIS- presents several years after
initial exposure
 CONGENITAL- e.g patent vitello-intestinal
duct(umbilical fistula)
 PATHOPHYSIOLOGY
• Loss of GI Content
Hypovolaemia, Acid-base and electro-
lyte abnormalities, Malnutrition.

• Sepsis
Intra-abdominal sepsis
Wound infection

• Skin problems.

• Anaemia
 MALNUTRITION
 Portion of gut below the fistula is by-passed resulting in malabsorption of essential
nutrients
 Fistula + complications + catabolic effects of sepsis = increased energy expenditure
 Body stores of glycogen & fat are progressively depleted & proteins mainly from
muscles-***first to go are intercostals hence lung infections
 Vit & trace element def. also occur
 Resistance to infection & impaired wound healing
 SEPSIS
 If fistula track is not effectively walled off from surrounding structures , there is
escape of enteric content into normally sterile areas such as peritoneal or pleural
cavities
 Fistula is unlikely to close in presence of sepsis
 Assoc. toxaemia & circulatory disturbances may result in multiple organ failure
DETERMINANTS OF FLUID
LOSS
 High fluid loss:
 Large fistula

 High fistula

 Distal obstruction
 MANAGEMENT PROTOCOL
 Surgeons have made advances in fluid, electrolyte replacement & nutritional
support
 these measures have allowed surgeons to maintain pts in a good condition
 This is done until the fistula closes spontaneously or the pt becomes fit for a
reparative surgical procedure
 Early surgical closure is no longer encouraged (Monod Broca 1977)
 MGT PROTOCOL CONT
 Sheldon et al(1971) suggested a four phase approach that could successfully put
mgt priorities in order
 It is still the guideline for management
PHASE
I. Resuscitation & stoma care
II. Institution of nutritional treatment
III. Investigations & continuing nutritional Rx
IV. Definitive treatment plan
 PHASE I
 RESUSCITATION-patients here are referred septic early post op
-correct fluid and electrolyte deficits using appropriate substitute
-blood transfusion as required
-maintain on daily requrements+estimated loss via fistula
 PROTECTION OF SKIN & COLLECTION OF FISTULA EFFLUENT
 main aim of stoma mgt is the application of effective skin protectives & a
disposable drainage bag which will collect effluent & allow accurate measurement
 Certain problems are associated with the stoma
 PHASE I
 These were classified by Irving & Beadle(1982) into four categories
 Aim is to aid mgt.
I. A single orifice passing thru an intact abdominal Wall or otherwise healed scar
around which the skin is flat & in reasonably good condition
II. Single or multiple orifices passing thru the abdominal wall close to bony
prominences, surgical Scars, other stomas, the umbilicus
III. Fistula thru small dehiscence of main wound
IV. Fistula thru a large dehiscence or at bottom of gaping wounds
 PHASE I
Stoma mgt cat. 1-silicon barrier preparation
-apply adhesive drainable bags
Extra skin protection(adhesive wafers)-in high output fistula

Stoma mgt cat 2-severely excoriated skin, impossible for any appliance to adhere
-Nurse pt face down on a split bed or Stryker frame for up to 48hrs
 PHASE I
Stoma mgt cat 2 cont- use large sheets of adhesive wafer(20x20)

-cut to fit various holes in the abd

-protective paste can be used to seal edges
-Apply large bag(sometimes 2 or 3 small bags)
-if abd scarred by previous surg, resulting grooves & gullies shd be filled

Stoma mgt cat 3- use adhesive wafers

-large sized bags
 PHASE I
Stoma mgt cat 4

-Initially low pressure sump suction drainage to remove effluent

-This is continued until the wound shrinks to a size that can be managed by the
techniques described above
 PHASE II
 Aim is to provide adequate & sustained nutritional Rx in order to maintain the
pt, until the fistula closes spontaneously or until the pt is fit for surgery.
 Bowel is still the best route to feed if enough bowel is available
 High output or proximal fistula- commence parenteral nutrition within
48hrs.once phase I procedures have been completed

 If subsequent investigation reveal >100cm of functioning small bowel, proximal

or distal to the fistula, it may be possible to phase in enteral regimens
 PHASE II
 Different formulations are available today to meet the patients needs
 Polymeric(blenderized hydrolysates), elemental(chemically defined), disease
specific(special purpose formulation), supplemental(modular protein, fat, CHO
to fit individual patient)
 Liquids are(isocal, clinifeed,favour, nutrauxil)
 Powders(flexical, casilan, vivovex HN, complan, forceval, protein)
 There is one for every patient
 Local formulations specific for common types of fistula made be constituted
 Bowel still remains the best route but parenteral are also available
 Central cannulation favours high osmolality(PICC, CL)
 Intralipids 10% or 20%, viamin 9 glucose, synthamin 14
PHASE III
• Once nutritional Rx has been established the pt is investigated fully to answer the
following questions
1. What is the origin of the fistula & the anatomy of its track
2. What is the condition of the bowel at the site of the fistula? discontinuity or active
disease
3. Is there obstruction distal to the fistula?
4. How much normal bowel is available?
5. Is there an assoc. abscess cavity?
PHASE III
CLINICAL EVALUATION
 Hx of surgery
 Hx of discharging wound from surgical scar or any other part of the body
 Hx of underlying dx
 Hx of fever, abd. Pain
 Hx of bowel habit; is pt passing stool or not

 Examination findings
 Fever, tarchycardia, abd. Tenderness, guarding, rigidity
 Signs of Dehydration & Malnutrition
 Discharging wound
INVESTIGATIONS
 FISTULOGRAPHY- valuable for narrow well defined fistula opening, doubtful value
for high output fistula in depths of gaping wounds
-outline track & abscess cavity
 BARIUM CONTRAST STUDIES-outline track, abscess cavity, demonstrate length of
remaining bowel
 ULRASOUND SCANNING- abscess cavity
 CT SCAN- abscess cavity, Percut. Drainage
 ENDOSCOPY- useful in revealing underlying dx
 ROUTINE INVX- Fbc, U&E
PHASE IV
 If pt is improving & flow charts indicate a falling fistula effluent & a rising plasma
albumin & body wt- it is worth persisting with non-surgical Rx without time
limit(Alexander Williams & Irving 1982)
 However, if peritonitis or abscess cavity is present- urgent operative Rx shd be
instituted
 In the absence of spontaneous closure within 4-6wks of nutritional support- surgical
closure shd be undertaken
PHASE IV
FACTORS RESULTING IN FAILURE OF SPONTANEOUS CLOSURE
 Complicated fistula with abscess cavity

 Distal obstruction

 Total discontinuity of bowel ends

 Mucocut. Continuity(short track <2cm) or epithelialized track

 Radiation enteritis

 Presence of active dx at site of fistula

PHASE IV
TREATMENT OF COMPLICATIONS

 Infection- antibiotics indicated in resp, uti, septicaemia, spreading cellulitis, I & D

for abscess

 Haemorrhage-bleeding may arise from

I. Erosion of a bld vessel by an abscess cavity

II. Stress ulceration due to assoc severe sepsis

III. From underlying dx e.g pud, neoplasm

RX-H2 antagonist
PHASE IV
-pack abscess cavity following drainage

-selective embolization

 Venous thromboembolism

-Anticoagulants

PHARMACOLOGIC TREATMENT
 H2 Antagonist – gastroduodonal fistulae

 Somatostatin Analogues (Octreotide) – small bowel fistulae

PRINCIPLES OF SURGICAL OPERATION FOR
MGT OF ECF
 Those designed to improve pts condition
 drainage for abscesses
 Insertion of central lines
 Creation of feeding enterostomies

 Those designed to close the fistula

 May be a staged procedure
 Informed consent
 Review previous surgery notes
 Incision shd be extensive, commencing from virgin area of abdomen
 Avoid the scar,sharp disection
 In septic pts- initial resection, anastomosis at a later date
 In non septic pts- resection + primary end to end anastomosis
Closure of defect

 No Preoperative Fascial Defect

Primary closure with or without fascial relaxation
 Preoperative Fascial Defect
<5cm Primary closure with or without fascial relaxation
 Large defect
Primary closure with component separation technic
Synthetic closure eg vascularized flap
Prosthetic material-absorbable or non absorbable
PREVENTION

 Better to prevent than treat

 Training and retraining of surgeon is important
 Identification of high risk individuals.
 Meticulous surgical technique.
 Proper use of peri-operative antibiotics.
 preoperative bowel preparation for some surgeons
 Early nutritional rehabilitation
CONCLUSION

 Most uncomplicated ECF will close spontaneously when

properly managed

 Surgery is usually not an immediate priority except to

deal with complications

 When surgery is required, fistula resection &

anastomosis or by-pass procedures are the preferred
surgical procedures
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