Details about Enterocutaneous FIstula

1. MANAGEMENT
OF
ENTERO-CUTANEOUS FISTULA
DR. Bikash Bk Thapa
MS- General Surgery
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2. • A Fistula is defined as an abnormal
communication between two epithelized
surfaces.
• Enterocutaneous fistulas (ECFs) are abnormal
communications between the bowel and skin
• Morality rate of 6.5 to 21%.
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3. HISTORY
• The earliest record of an enterocutaneous Fistula
appears in the old Testament Book of judges Written BY
Samuel Between 1043 BC and 1004 BC.
• Celsus described the first reported attempt of surgical
repair of a colocutaneous fistula.
• In the 18th century John Hunter advocated a conservative
approach to fistulas after he noted that fistulas
occasionally close spontaneously.
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4. •In early 1900’s enterostomy was made in healthy bowel
proximally in obstructed bowel
•This often would close spontaneously on resolution of
obstruction
•This lead to an unrealistic optimistic approach towards all
enterocutaneous fistulas
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5. CLASSIFICATION
Anatomical classification:
(1)
Internal: Two organ of same or different system
• Enteroenteral, enterovesical,enterocolic,
External: Gut to body surface.
• Gastrocutaneous,duodenocutaneous, enterocutaneous.
(2)
Simple or direct.
Complicated-
1.Having multiple tracts
2. Connection with more than one viscus
3. drainage into an associated abscess cavity.
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6. Physiological classification
• High output- output more than 500 ml/ day
• Moderate output- output 200-500 ml/day
• Low output- output less than 200ml/day
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7. Etiologic Classification
• Radiation
• Inflammatory bowel
disease
• Diverticular disease
• Appendicitis
• Ischaemic bowel
disease
• Duodenal ulcer
perforation
• Malignancies
• Intestinal tuberculosis
• Actinomycosis.
1. Spontaneous(15-25%)-
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8. 2. Post-operative (75-85%)
• Operations for
perforations
• Acute intestinal
obstruction
• Intestinal malignancies
• Adhesiolysis
• Blunt and penetrating
abdominal trauma
• .
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9. 3. Congenital
– Tracheo- esophageal
– Rectovaginal
– Umbilical fistula.
4. Traumatic
– Blunt and penetrating trauma of abdomen, chest
and perineum
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10. ETIOLOGY
• Disease bowel extending to surrounding structures
• Extraintestinal disease involving otherwise normal
bowel
• Trauma to normal bowel including inadverent or
missed enterotomies
• Anostomotic disruption following surgery for a
vareity of conditions
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11. • Small intestinal fistula are most common type
of gastrointestinal fistulas encountered.
• Most series report 70%-90-% of small
intestinal fistulas occurs after an operative
procedure.
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12. Factors Influencing
• Malnutriton
• Infection
• Hypotension
• Anemia
• Hypothermia
• Poor oxygen delivery
• Mobilisation
• Handling
• Tension
• Ischemia
• hemostasis
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13. Nutritional characteristics have been suggested to
increase the risk of anastomotic breakdown:
1. Weight loss of 10–15% of total body weight over 3–4
months;
2. Serum albumin less than 3 mg/dL;
3. Serum transferrin less than 220 mg/dL;
4. Anergy to recall antigens; or
5. Inability to perform activities of daily living due to
weakness or fatigue.
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14. PATHOPHYSIOLOGY
• Fluid and electrolyte imbalance.
• Malnutrition
• Sepsis
• Skin irritation and excoriation
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16. PREDICTIVE FACTORS FOR SPONTANEOUS CLOSURE
FACTORS FAVORABLE UNFAVORABLE
ORIGIN Orophyrayngeal, esophageal,
duodenal , PB, Jejunal, colonic
Gastric, lateral duodenal, ligment
of teritz, ileal
EITOLOGY Postop, appendicitis, diverticulitis Maligancy, IBD
OUTPUT low high
NUTRITION Well nourished
transferrin > 200 mg/dl
Malnourished
< 200 mg/dl
SEPSIS Absebt Present
STATE OF BOWEL Healthy adj tissue, intestinal
continuity, absence of obstruction
Ds adj bowel, distal obst, large
abscess, bowel discont, prev
irradiation
FISTULA Tract > 2 cm, defect < 1cm sq Tract < 1cm, defect > 1cm sq,
epithelilisation, FB
MISC Same institution Refered
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18. Avg. Time to closure
• Varies with anatomical location
1. Esophageal- 15-25 days
2. Duodenal- 30-40 days
3. Colonic - 30- 40 days
4. Small Bowel- 40-60 days
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19. MANAGEMENT
THE GOAL are
• Re-establishment of bowel continuity
• Ability to achieve oral nutrition
• Closure of the fistula
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20. MANAGEMENT PHASES
PHASE TIME COURSE
RECOGNITON /
STABILISATION
24 TO 48 HRS
INVESTIGATON 7- 10 DAYS
DECISION 10 DAYS TO 6 WEEKS
DEFINITIVE
MANAGEMENT
WHEN CLOSURE UNLIKELY OR 4-6
WKS
HEALING 5 – 10 DAYS AFTER CLOSURE
UNTILL FULL ORAL NUTRITON
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21. Recogniton/stabilisation
• Resuscitation
• Control of sepsis
• Electrolyte repletion
• Provision of nutrition
• Control of fistula drainage
• Local skin care n protection
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22. Clinical presentation
• Recognized 5th-10th days
post operatively.
• Fever/ shock
• Prolonged ileus
• Erythema of wound
• Abdominal tenderness
• Drainage of enteric material
through the abdominal
wound or through or existing
drains.
• leucocystosis
• confirmation can be obtained
by oral administration of a
nonabsorbable marker, such
as charcoal or Congo red
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23. Resuscitation :
– Restoration of normal circulating blood volume
• Hct- 30%
– Correction of electrolyte & acid base imbalance.
– Plasma oncotic pressure should be restored by
exogenous albumin administration. - 3 mg/dl
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24. Control of Sepsis
• Management of local wound infections
• Drainage if Intra-abdominal collections (percutaneous)
• Laparotomy may be required for:
– Extensive cellulitis/necrotising fascitis
– Incomplete percutaneous drainage of collections
– Disruption of anastomosis
• Antibiotics as per indicated
• CVP only after 24 hrs of drainage
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25. Skin care management:
• Problems in skin around the fistula:
– Wetness
– Burning pain
– Discomfort from skin edema
• Goals of skin care:
– Containing the effluent
– Patient independence and mobility
T
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26. Skin Barriers:
– Solid wafers (pectin based)
– Powders (Pectin / Karaya based)
– Paste
– Spray and wipes
– Ointments and creams (zinc/petroleum based)
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27. Techniques of skin care:
• Wound pouch dressings
– One/two piece design
– Clip closure or Urostomy type
– May be attached to a bed side bag or suction
catheter
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28. Wound pouch dressing
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30. Sump Drainage:
– For fistulae draining with open abdominal wound.
– Large bore drains or sumps
– High pressure suction
VAC
• Removes chronic edema, leading to increased localized blood flow, and
the applied forces result in the enhanced formation of granulation
tissue”
Fistuloscopy with fibrin glue injection Closure within 2-30 days.
(Eleftheriadis, 2002)
Dry dressing
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32. Reduction of fistula output
• Restrict hypo-osmolar fluids
• Encourage electrolyte mix
• Antisecretory agents
– Proton pump inhibitors
– Somatostatin or octreotide
• Antimotility agents
– Loperamide
– Codeine British Journal of Surgery 2006; 93: 1045–1055
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33. SOMATOSTATIN N ANALOGUE
• Naturally occuring peptide hormone
• Inhibitory to gastrointestinal secrection
• Plasma half life 1-2 min
• Mode
– Inhibit gastrin n cholecystokinin
– Reduces splanchic blood flow
– Reduces rate gastric emptying
– Inhibit gall bladder contraction
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34. Randomized clinical trials of octreotide and somatostatin use
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35. Reduction of fistula output
•Infliximab (monoclonal antibody) (in Crohn’s disese)
•Oral tacrolimus (in Crohn’s disese)
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36. • Nasogastric tubes : should be removed if
– There is a no obstruction.
– Fistula is a low in intestinal tract.
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37. Nutritional management:
– Plays Central role in management
– Adequate circulation and tissue oxygenation must
for optimal utilization.
– May be:
• Enteral
• Parenteral
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38. •Chapman and colleagues demonstrated that patients
receiving optimal nutritional support (3000 calories per
day) had a mortality rate of 12% as compared to 55%
mortality among patients receiving a sub optimal
nutritional regimen.
•Robauk and Nichdoff reported closure of 73% enteric
fistulae in patients with adequate caloric
supplementation but only 19% healed when nutritional
support was inadequate.
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39. General guidelines
• 25–32 kcal/kg/day with a calorie:nitrogen
ratio of 150:1 to 100:1 and at least 1.5 grams
per kilogram per day of
• Patients should receive 3000 to 5000 non
proteins calories per day
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40. • Patients daily protein requirement is 1.2 to
2.0 gm kg/day.
• Fluid requirement is 30ml/kg/day.
• Electrolyte requirement/day
• Na-70-100 meq/day
• K- 70-100 meq/day
• Mg- 15-20 meq/day
• Ca- 10-20 meq/day
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41. Recommended Nutritional Support
Low Output High Output
Form Enteral Usually Parenteral
Protein 1-1.5g/kg/day 1.5-2.5g/kg/day
Calories BEE BEE x 1.5
Lipids Enteral (20-30%) Parenteral (20-30%)
Vitamins RDA
Vit C – 2RDA
2RDA
Vit C – 5 –10RDA
Minerals Usually not needed Close watch
Vitamin K 10mg/wk 10mg/wk
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42. TPN strategy
If BW loss> 20%, TPN initiated gradually to avoid
refeeding syndrome
J Clin Gastroenterol 2000; 31(3)
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43. Harris Benedict Equation
• BEE in kcal per day for men =
66.4 + (13.7 × weight in kg) + (5.0 × height in cm)
– (6.7 × age in years)
• BEE in kcal per day for women =
655 + (9.6 × weight in kg) + (1.8 × height in cm) –
(4.7 × age in years)
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44. TPN indications
• Inability to obtain enteral access
• High output fistulas
• GI intolerance with enteral nutrition
• Multiple unfavorable factors (ileus, obst, )
• Not proven well in mortality reduction in ECF,
but improve spontaneous closure
J Clin Gastroenterol 2000; 31(3)
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45. TPN
• Conc. dextrose: 500ml of 20% Dex. (=400 kcal)
• Fat: 500 ml 10% fat emulsion (=450 kcal)
• Crystalline Amino Acids: 500 ml 10% Amino acids
(=8.4 g Nitrogen)
• Daily Vitamin Supplementation ( Vit. K 10 mg/wk)
• Rate of infusion
• Starting: 50 – 100 ml/hr
• Gradually increased by 25 – 50 ml/hr every second day
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46. Patient Monitoring:
• Clinically: (daily)
– Sense of well being
– Graded activity
– Vitals
– Weight / input-output
• Laboratory profile: (daily until patient stable then twice weekly)
– Serum albumin
– Serum Electrolytes
– RFT
– LFT/ coagulation profile
– Lipid profile
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47. Complications of TPN
• Mechanical
– Catheter tip malposition (6%)
– Arterial laceration (1.4%)
– Hydro-pneumo-haemo thorax (1.1%)
– Subclavian/Superior vena cava thrombosis (0.3%)
– Thrombophlebitis (0.1%)
– Catheter embolism (0.1%)
• Septic
– Catheter related sepsis (7.4%)
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48. • Metabolic
– Acute
• Hyperglycemia/hypoglycemia
• Electrolyte abnormalities
• Fluid overload
• Hyperlipidemia
– Chronic
• Metabolic bone disease
• Alterations in bile composition
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49. Enteral Nutrition
nasogastic/nasoenteric/fistuloclysis
• Benefits:
– Trophic effect on bowel
– Stimulates hepatic protein synthesis
– Improve immune / hormaonal/ barrier function
– Dec infection rate/ metabolic complication
– Inexpensive
• 4 ft of functional bowel/ distal patency required
• Lipid based formula absorbed more efficiently
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50. INVESTIGATION (7-10 days)
Objectives of investigation plan: To define-
• Precise anatomical location
• Is the bowel in continuity or is disrupted
• Abscess cavity
• Condition of adjacent bowel
• Is there a distal obstruction
• Etiological disease process
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51. Radiological contrast studies
• Fistulography :.
• Barium transit studies :
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53. CT- Scan
Gastro cutaneous fistula
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Entero colic fistula Sigmoid cutaneous fistula

54. Endoscopic studies
• Gastro duodenoscopy : Demonstrates both
underlying disease and presence of fistula.
• Colonoscopy : Fistula is usually not visible but
presence of disease and its nature by biopsy can be
demonstrated.
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55. DECISION: (10 days – 6 wks)
Evaluate the likelihood of spontaneous closure
Decide duration of trial of nonoperative management
• No signs of imminent closure after 4- 6 weeks then patient
should be prepared for surgery.
• Unfavorable characteristics since beginning
• Uncontrolled sepsis urgent drainage of sepsis.
• General condition very poor then only abscess drainage
• In case of malignancies early operation should be done.
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56. • 90 – 95 % of fistulas that will spontaneously
close typically do so within 5 weeks of
operation
• Operation during the first 10 days to 6 weeks
from diagnosis of postoperative fistulas is
made more difficult by the obliterative
peritonitis
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57. Extreme
Great
Moderate
Minimal
Severity of Adhesions
0 7 14 21 28 42 56 84 6 months
Time after Operation
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58. Window Period
• 7 to 12 days from the most recent laparatomy
• Within this “window period” severity of adhesions
are usually milder and repeat laparotomy with the
intent of diverting and or repairing the fistula is
justified since caring for a well matured stoma is
much easier than ECF.
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59. Why not to operate outside the window period?
• risk of further enterotomy, and fistula formation
and devascularization of the small
• If operation occurred outside the window and is
difficult ,put tube gastrostomy and “GET OUT”
• Defer any attempt of repeat laparotomy up to 4
preferably to 6 months
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60. DEFINITIVE MANAGEMENT
plan operative approach
• Optimal nutrition parameters
• Free of sepsis
• Well healed abdominal wall without inflammation
• Prophylactic antibiotics
• Tapering of tube feeding
• Operative approach preferably through a new incision
– Transeverse
– Midline
• Prevent contamination of abdominal wall tissues
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61. • Bowel refunctionalisation
– Free all adhesion
– Drain any abscess
– Releive any obstruction
• Disection/ Adhesiolysis –
– Start with least dense adhesion
– Sharp Dissection
– Wet laparotomy pads
– Saline injection (hydro dissection)
– Extrafascial dissection
• Repair enterotomies – Heineke- Mikulicz
• Repair serosal tears- Lembert sutures ( 5-0 prolene)
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62. • Best results are with definitive resection and EEA
• > 1/2 circumference be treated by resection and
anastomosis
• Direct attack on duodenal fistula is unwise
• Tube duodenostomy to prevent duodenal stump blow out
• Proximal diverting stoma / Tube enterostomy
• Omental flap – to prevent fistulization
• Stomas with mucus fistula or exteriorization
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63. • Protective diverting stoma proximal to anastomosis
• Secure closure of abdominal wall over the fistula
• Decompression gastrostomy
• Post-op nasogastric decompression
• Feeding jejunostomy ( for proximal fistulae)
• Post op continuation of nutrition with gradual shift
from parenteral to enteral form
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71. HEALING
• ensure that the patient receive full nutritional support.
• Adequate protein and calories
• Parenteral and enteral supplementation in an overlapping
• Contibue NG feeding untill 1500 kcal/ day orally
• Oral feeding – 1 week with soft diet
• Zinc supplement
• Cycling tube feedings
• Psychological n emotional support
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72. Late Complications:
• Short bowel syndrome (after multiple fistula repair)
• Stricture and partial obstruction at fistula site
• Esophageal stricture after prolonged nasogastric
sump decompression
• Neuropsychiatric problems
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73. Prevention of Fistula:
• Prophylactic Antibiotics and Bowel Preparation:
– Polythelene glycol administrtion decreases bacterial load
from 10 12-15 to 10 4-5
– Enteral non-absorbable antibiotics reduce it to 10 2-3
– Prophylactic I/v antibiotic at time of induction of
anaesthesia with repetition of dose in case of prolonged
surgery
– Post op continuation of antibiotic
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74. • Appropriate hydration to prevent Hypotension and compromised
circulation
• Anastomosis in healthy bowel with adequate blood supply;
without tension
• Meticulous and precise hemostasis
• Selection of proper needle size,suture
• Omental covering if possible
• Dead space obliterated with live tissue and properly drained
• Drains kept away from anastomosis site
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