enterocutaneous fistula - definition, clinical features, and treatment

1. ENTEROCUTANEOUS FISTULA
Dr . S. Preethiya.
Post graduate
Department of General Surgery

2. INTRODUCTION
• It is an abnormal communication between the skin with various part of gut, for
example duodenum, jejunum ..etc
• Ileum is the most common site of origin

3. AETIOLOGY
• Post operative
Disruption of anastomosis
Inadvertent enterotomy – occurs in pts with adhesions, when
dissection can cause multiple serosal tears and occasional full
thickness tear
Inadvertent small bowel injury – occurs during abdominal closure ,
especially after ventral hernia repair

4. • Traumatic
Iatrogenic trauma to bowel that may or may not be recognized.
RTA with injury to gut also lead to ECF
Damage control laparotomy technique have higher risk of delayed ECF
formation

5. • Spontaneous
• Malignancy
• Radiation enteritis with perforation
• Intra-abdominal sepsis
• IBD ( eg . Crohn disease)

6. FACTORS WHICH FAVOURS SPONTANEOUS CLOSURE
• End fistula ( example . Those arising from leakage through a duodenal stump )
• Jejunal fistulas
• Colonic fistulas
• Continuity maintained fistula – allow patient to pass stool
• Small defect fistulas
• Long tract fistulas

7. FACTORS WHICH ARE UNFAVORABLE FOR SPONTANEOUS CLOSURE
• Foreign body
• Radiation
• Inflammation / infection / IBD
• Neoplasm
• Distal obstruction
• High output ( > 500 ml/24 hr)
• Fistula tract < 2.5 cm long
• Epithelialization of fistula tract.

8. 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 breakup should be avoided to
prevent serosal tears .

9. DIAGNOSIS OF PERFORATION AND FISTULA
• Post op anastomotic leaks/ unrecognized perforations and subsequent fistulae
may manifest as instability or pts failure to improve
• Fever , abdominal pain followed by exiting of intestinal contents from drain or
incision site
• Occasionally heavily purulent discharge may mistaken an ECF like in enteric
perforations
• Activated charcoal or indigo carmine by mouth can help in diagnosing ECF

10. • Intraluminal instillation of methylene blue and saline or direct endoscopy helps to
identify small perforations.
• Investigations done after 7- 10 days following stabilization
• USG abdomen helps in locating intra abdominal abscess
• Fistulography – defining the length , width of fistula , anatomical location , presence
of any distal obstructions

11. • It should be followed up with complete
contrast study of GI tract
• Fistulogram should be performed before an
upper GI series or CT scan with oral
contrast or contrast enema as it poses
difficulty in interpretation.
• .

12. • CT–Abdomen with IV contrast
• Endoscopy – used occasionally though its
principal use is in internal fistula , usually
delayed till acute inflammation gets reduced

13. STAGING AND CLASSIFFICATION
• Anatomical classification : Internal or External fistula
 Internal fistula are named after the structures it communicated like
gastrocolic , jejunoileal , aorto-enteric fistula.
 External fistula like gastric, duodenal, jejunal , ileal or faecal .

14. • 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)

15. MANAGEMENT
[S - S –N-A-P]
1. Stabilization
2. Control of sepsis and appropriate skin care
3. Nutrition
4. Define underlying anatomy
5. Plan to deal with fistula

16. STABILIZATION AND RESUSCITATION
• 1st step – resuscitation and stabilization of patient , needs to be accomplished
within the first 24 to 48 hrs of management
• IV fluids resuscitation( isotonic fluid ) , control of infection , protection of
surrounding and replacing ongoing losses
• Intra-abdominal / subcutaneous abscesses – should be drained

17. NUTRITION
• ECF usually associated with hypokalaemia and metabolic acidosis – require correction
• Urine output should be restored > 0.5 ml/kg/hr
 Can be given by parenteral or enteral route , based on anatomy of fistula
 Nutrition via enteral route helps in maintaining the intestinal mucosal barrier , more
efficacious delivery of nutrients stimulating hepatic protein synthesis

18.  In proximal fistulae – enteral feeding tube may be entered beyond the fistula
to provide enteral nutrition
 Advisable to enter feeding tube beyond ligament of Treitz for a gastric or
duodenal fistula
 TPN is also given in pts who do not tolerate enteral feeds or have long
standing ileus or before fistulous tract is well established
Type of fistula Calorie requirement Protein requirement
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

19. CONTROL OF SEPSIS AND FISTULA EFFLUENT
Persistent fever , tachycardia and leucocytosis along with failure to
improve adequately points towards possible sepsis or abscesses .
May require surgical drainage of abscess with antibiotic cover

20. Local skin care and prevention of skin
excoriation by using stomahesive paste or
aluminium paint etc along with stoma bags .
VAC( vacuum assisted closure ) devise
drainage system may be used too
VACUUM ASSISTED DRESSING

21. PHARMACOLOGICAL SUPPORT
• Somatostatin analogue octreotide – doses of 100-250 mg TDS reduces fistula output by 40 -60
% by the end of 24hrs
 Discontinued if ineffective for 48 hrs as it has side effects like hyperglycaemias, 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

22. • Proton pump inhibitors and H2 receptor antagonists also helps reduce fistula output
especially in proximal fistula
• Cyclosporin – doses of 4 mg/kg/day for 6 – 10 days followed by oral doses of
8mg/kg/day helps to treat refractory fistulae associated with crohn’s disease
• Other drugs include Tacrolimus , Azathioprine ,, 6- MP , Infliximab
• Infliximab administered at a dose of 5 mg/kg/day IV at 0,2,6 weeks
• Complications – URTI , headache , fatigue

23. DEFINITIVE THERAPY
• Majority will close within 6 weeks with conservative management
• Surgery between 10 days and 6 weeks post op will encounter the worst
adhesions
• Preferably wait up to 6 weeks before open exploration and repair of defect ,
but in case of fistula , due to dense intense inflammation - wait till 10- 12
weeks

24. • Preferred surgery – resection of involved segment with primary end-to – end anastomosis
 If primary anastomosis is not possible , proximal and distal ends of intestine are exteriorized
• If fistula is deemed inappropriate for resection , staged approach involving bypass should be
considered.
 In staged procedure – fistulous segment left in-situ and the afferent and efferent bowel loops
are anastomosed to restore intestinal continuity
 Staged procedure is complete d when fistula segment of removed at later date

25. • Enteroatmospheric fistula usually require multiple staged procedure
• VAC devised used initially to approximate the large abdominal defect along with
isolation of fistula by ostomy bags
• After proper granulation tissue formation , stabilized patient can be considered for
SSG

26. • Musculocutaneous flaps, abdominal wall
reconstruction by component separation
technique , use o prosthetic materials , especially
biologics may also be necessary .
• If the gastric fistula defect is large – Roux-en-Y
gastrojejunostomy may be done

27. • Duodenal fistula usually treated with tube
duodenostomy or Roux-en –Y
duodenojejunostomy
• Feeding jejunostomy distal to
enteroenterostomy should always be
considered .