Enterocutaneous fistula

1. Entero-cutaneous Fistulas
By : Dr. Anurag

2. INTRODUCTIONINTRODUCTION
Fistula is defined as an abnormal communication between two epithelialized
surfaces.
Enterocutaneous fistula is an abnormal communication between the skin with
various parts of the gut, such as duodenum, jejunum etc.
The word fistula means a “pipe” or “flute” in Latin.
 The ileum is the most common site of origin of Enterocutaneous fistula.

3. CLASSIFICATION

5. ETIOLOGYETIOLOGY
Webster and Carey proposed five mechanisms of fistula formation :
1> Congenital : - Rare
- Failure of obliterate of Vitello-intestinal duct.
- Post natal slough of the stump.
2> Trauma : - Major penetrating trauma.
- Damage control laparotomy techniques

6. 3> Infection : - intra abdominal Abscess and invasive intestinal infections like
amoebiasis, coccidiomycosis, tuberculosis etc.
- Intestinal perforation in ileum from tuberculosis or enteric fever
- Actinomyces infection post appendectomy.
4> Iatrogenic :
- Intra-abdominal abscess
- 75-85% are iatrogenic - after surgery for bowel obstruction,
cancer, or IBD

7. 5> Inflammation, Irradiation or Tumour :
- Crohn’s disease may cause ECF – post op more common
than spontaneous.
- ECF after anastomosis/appendicectomy/simple exploration
in Crohn’s disease.
- Irradiation for pelvic malignancies etc may lead to a chronic
non-healing ECF.

8. PREVENTION OF FISTULAPREVENTION OF FISTULA
- Acute intra-operative perforations- early identification and closure.
- Serosal tears should be repaired immediately.
- Aggressive adhesiolysis should be avoided to prevent serosal
tears.

9. Post operatively anastomotic leak
Fever
Abdominal pain
Continuous drain containing intestinal content
General condition not improving
DIAGNOSIS OF PERFORATION AND FISTULADIAGNOSIS OF PERFORATION AND FISTULA

10. STAGING AND CLASSIFICATIONSTAGING AND CLASSIFICATION

11. • Stabilization
• Sepsis control
• Skin care
• Nutrition
• Anatomy identification
• Plan to deal with the fistula
MANAGEMENTMANAGEMENT
S-S-N-A-PS-S-N-A-P

12. STABILIZATIONSTABILIZATION
 In 24 to 48 hours.
 First step - resuscitation and stabilization of the patient.
 Initial efforts –
intravenous fluid resuscitation
control of infection
protection of surrounding skin
measuring and replacing ongoing losses.
> Intra-abdominal/subcutaneous abscesses should be drained

13. A. RESUSCITATIONA. RESUSCITATION
 Restoration of normal circulating blood volume
 correction of electrolyte and acid-base imbalance
 Initial management- RL and NS
 Strict input and output measurements
 CVP monitoring
 urinary catheterization.
 Ongoing fluid losses should be fully replaced
 Associated with hypokalemia and metabolic acidosis- correction.
 Output of fistula should be monitored
 Urine output should be restored to greater than 0.5mL/kg/hr.
 If needed transfuse blood.

14. B. NUTRITIONB. NUTRITION
 73% of enteric fistulae closes spontaneously in adequately nourished
patients,
as against 19% in malnourished patients.
> Nutritional support needs to begin as soon as the patient is stabilized.
> Nutrition can be parenteral or enteral route, based on the anatomy
of the fistula.
> Its advisable to provide at least a part of the daily nutritional requirement
through enteral route.(adequate is 25%).
> Nutrition via the enteral route helps in maintaining the intestinal mucosal
barrier, more efficacious delivery of nutrients, stimulating hepatic protein
synthesis.
> ORS should be given when oral intake is possible.
> In proximal fistulae, the enteral feeding tube may be entered beyond the
fistula to provide enteral nutrition.
> It is advisable to enter feeding tube beyond ligament of Treitz for a gastric
or duodenal fistula.
TPN is also given in patients who do not tolerate enteral feeds or have
long standing ileus or before fistulous tract is well established.

15. NUTRITION CONTD..NUTRITION CONTD..
vitamins, trace elements, zinc and up to 10 times the daily requirement of
Vitamin C should be provided.
> Mortality rate of 42% with albumin <2.5 mg/dl v/s 0% if >3.5 mg/dl.
TYPE OF FISTULA CALORIE REQ PROTEIN REQ
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

16. C. CONTROL OF SEPSIS AND FISTULA EFFLUENTC. CONTROL OF SEPSIS AND FISTULA EFFLUENT

18. D. PHARMACOLOGICAL SUPPORTD. PHARMACOLOGICAL SUPPORT
> Somatostatin analogue Octreotide-100 – 250 mcg TDS reduces
fistula output by 40 – 60% by the end of 24 hrs.
> Should be discontinued if ineffective for 48 hrs (side effects-
hyperglycemia, 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.
> Proton-pump inhibitors and H2 receptor antagonists also help reduce fistula
output especially in proximal fistulas.
> Complications include URTI, headache, fatigue etc.

19. INVESTIGATIONSINVESTIGATIONS
To locate Fistula
X-ray- show any foreign body
Oral dye / Charcoal – shows presence or absence,
but not its location, cause or anatomy.
USG - locating intra-abdominal abscesses, guided aspiration
Fistulography- length & width of the fistula, anatomical
location, the presence of any distal obstructions
CT Scan- oral and IV- highly recommended for duodenal & pancreatic fistula.
Endoscopy -principal use is in internal fistulas.

21. DECISIONDECISION
Factor Favorable Unfavorable
Organ of origin Esophageal, Duodenal stump,
Pancreatic, Biliary, Jejunal,
Colonic
Gastric, Lateral
duodenal, Ligament of
Treitz, Ileal
Etiology Postop (anast leak),
Appendicitis, Diverticulitis
Malignancy, IBD
Output Low (<200-500cc/day) High (>500cc/day)
Nutritional status Well nourished Malnourished
Sepsis Absent Present
State of bowel Intestinal continuity, absence
of obstruction
Distal obstruction,
Abscess, Discontinuity,
Irradiation
Fistula
characteristics
Tract >2 cm, Defect <1cm Tract <1cm, Defect >1cm
Miscellaneous Original operation at same
institution
Referred from outside
institution

22.  90% of small intestinal fistula which closed spontaneously within a month.
 10 % fistulas closes spontaneously after 2 months and none after 3 months
 Factors possibly responsible for failure of spontaneous closure are:
 Foreign Body
 Radiation
 Inflammation/ infection
 Epithelialization [F-R-I-E-N-D-S]
 Neoplasm
 Distal intestinal obstruction
 Steroids.

23. DEFINITIVE THERAPY

24. DEFINITIVE THERAPYDEFINITIVE THERAPY
> 80-90% 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 fecal fistula, due to intense inflammation, it is prudent to wait
up to 10-12 weeks.
> The patient should by then, be nutritionally optimized, patient should not be septic
and patient should be vitally stable.

25. > Definitive operative correction remains the final step in the treatment of
non-healing small intestinal fistulas.
> In majority of the cases, preferred operation is resection of the involved segment
with primary end-to-end anastomosis.
> However if primary anastomosis is not possible, then both the proximal and
distal ends of intestine are exteriorized.
> In case the fistula is deemed inappropriate for resection, such as when it
develops after a deep pelvic procedure, staged approach involving bypass
should be considered.

26. Basic principles of surgical treatment
• resection of the intestinal segment, fistula tract, and the
adjacent part of the involved structure
• absence of extensive infection or inflammation - primary
anastomosis of the divided intestinal segments and
reestablish GI continuity
• presence of extensive infection - the divided intestinal
segments are exteriorized.
• staged procedure is performed after the infection and
inflammation subsides to re-establish GI continuity and
reconstruction of the affected structure after 10 weeks.

27. Entero-cutaneous fistula :-
Resection of the involved segment with primary end-to-end anastomosis
Exteriorization of both ends in the presence of extensive intra-abdominal
sepsis
Bypass procedure when dense adhesions are encountered within the
pelvis.
Choice of procedure for specific fistula
types

28. Enteroenteric fistula
• In the absence of associated infection:- Primary anastomosis
of healthy bowel ends.
• In the presence of associated infection:- Proximal diversion
procedure with drainage of the abscess cavity.
• Resection of the involved intestine and fistula after 4-6 weeks.
• Resection should be limited to the area of intestine involved in
fistula formation.
• Extensive resection is not advantageous and only increases
the risks of subsequent short-bowel syndrome
and malabsorption.

29. Entero-vesical fistula
• Surgical resection of the diseased intestine and the involved
area of bladder wall.
• A primary anastomosis of the bowel is performed,
• The bladder wall is closed in layers.
• In presence of inflammation- transection of the intestinal
segment proximal and distal to the fistula, leaving the fistula
tract in place. Both ends of the intestine are exteriorized.

30. Nephroenteric fistula
• surgical procedure of choice is either total or partial
nephrectomy, with en-bloc resection of the fistula tract and
the involved intestinal segment. The ends of the intestines are
anastomosed primarily.

31. Enterovaginal fistula
• Surgery is reserved for patients who do not respond to
conservative treatment with antibiotics and drainage of
associated abscesses.
• An en-bloc resection of the involved intestinal segment with
fistula and affected vaginal wall is performed.
• The intestinal ends are anastomosed primarily and the vaginal
defect may be closed primarily.

32. Aortoenteric fistula
• Emergency surgical intervention
• The aortic prosthetic graft is removed
• The intestinal defect is debrided and closed primarily. The
presence of extensive inflammatory or devitalized tissue may
necessitate intestinal resection and an end-to-end
anastomosis.

33. ENTEROATMOSPHERIC FISTULAENTEROATMOSPHERIC FISTULA

35. > In 1995, Ho HS and Frey CF used primary closure of gastric fistula with
delayed external drainage as treatment for gastric fistulas.
> If the gastric fistula defect is too large to allow primary closure,then a
Roux-en-Y gastrojejunostomy may be done.
> Duodenal fistulas are usually treated with tube duodenostomy or Roux-en-Y
duodenojejunostomy.
> A feeding jejunostomy distal to the enteroenterostomy should always be
considered.

37. Roux-en-Y DuodenojejunostomyRoux-en-Y Duodenojejunostomy

38. CONCLUSIONCONCLUSION
> Enterocutaneous fistulas are abnormal communication between the gut
and skin.
> Majority of the ECF are due to iatrogenic causes (70-85%). Others include
trauma, congenital causes. Spontaneous ECF may arise due to Crohn’s
disease.
> Malnutrition, Electrolyte imbalances, acid-base imbalances and sepsis are
the major causes of mortality in ECF.
> After initial stabilization of the patient by resuscitation( fluid, electrolytes,
blood transfusions etc), the patient is subjected to various investigations
to determine the location& anatomy of fistula, presence of distal obstruction
etc.

39. > Enteral nutrition is always preferable to parenteral nutrition provided the
patient tolerates enteral feeds.
> Local wound care by application of ostomy bag and pastes are essential.
> Drainage of intra-abdominal abscesses, treatment of sepsis is of utmost
importance.
> After proper optimization, patient undergoes definitive therapy which
includes resection of the fistulous segment of the gut.
> ECF with large abdominal defects may require VAC devices/ biologic mesh
SSG to help close the defect.

40. THANK YOUTHANK YOU