MANAGEMENT OF MANAGEMENT OF ENTEROCUTANEOUS ENTEROCUTANEOUS FISTULAFISTULA

OUTLINEOUTLINE• INTRODUCTION INTRODUCTION

• PHYSIOLOGYPHYSIOLOGY

• PATHOPHYSIOLOGYPATHOPHYSIOLOGY

• CLINICAL FEATURESCLINICAL FEATURES

• PRINCIPLES OF MANAGEMENTPRINCIPLES OF MANAGEMENT

• PROGNOSTIC FACTORSPROGNOSTIC FACTORS

• PREVENTIONPREVENTION

• COMPLICATIONSCOMPLICATIONS

• CONCLUSIONCONCLUSION

INTRODUCTIONINTRODUCTION

• A fistula is an abnormal communication between two epithelial-lined surfaces

• Enterocutaneous fistula: btw intestine and skin

• Historical aspects[4]:– Antibiotic era 1945-60– Intensive care 1960-70– TPN era 1970-75

CLASSIFICATION

• High & Low - obsolete[4]

Types: NEW CLASSIFICATION Siteges-Sera et al modified by Schein et al

1. Abdominal oesophagus & gastroduodenal fistula

2. Small bowel fistula3. Large bowel fistula4. Any site with a large abdominal wall defect (N.B 3. has the best prognosis and 4 has the worst prognosis)

CLASSIFICATIONCLASSIFICATION

ANATOMICAL CLASSIFICATIONANATOMICAL CLASSIFICATION:

1. a. Simple or direct.

b. Complicated-

• 1.Having multiple tracts

• 2. Connection with more than one viscus

• 3. drainage into an associated abscess cavity.

• (2). Circumference of Bowel:1. LATERAL –side of a hollow viscus.2. END.- whole circumference.

AETIOPATHOLOGICALAETIOPATHOLOGICAL

• CongenitalCongenital– Umbilical fistula.

• AcquiredAcquired TRAUMA

BLUNT PENETRATING.

POST-OPERATIVE: 80%• ANASTOMOTIC LEAK

• UNRECOGNISED BOWEL INJURY. SURGERIES LIKELY TO LEAD TO THIS:

ADHESIOLYSIS SUTURE OF PERFORATIONS ANASTOMOSIS

SPONTANEOUS: NEOPLASTIC—MALIGNANCY INFLAMMATORY:

TB DIVERTICULAR DISEASE CROHNS DISEASE RADIATION ENTEROPATHY AMOEBIASIS.

PRESSURE: between two epithelial surfaces –

• gallbladder & duodenum, • stones in biliary ducts- Mirizzi,; • Obstructed ext . Hernias e.g Ritcher’s.

Umbilical/para

CONTRIBUTING FACTORSCONTRIBUTING FACTORS

• Malnutrition

• Sepsis

• Hypotension/Shock

• Vasopressors

• Steroids

• Radiotherapy

• Anastomotic factors

PHYSIOLOGYPHYSIOLOGY• Digestion/ absorption

• Water / Electrolyte absorption and secretion

• Carbohydrate digestion/ absorption

• Protein digestion/ absorption

• Fat digestion / absorption

• Vitamin/ mineral absorption

• Barrier / immune function

• Motility

• Endocrine function

PATHOPHYSIOLOGYPATHOPHYSIOLOGY

• Depends on structure involvedDepends on structure involved

• Loss of GI ContentLoss of GI ContentHypovolaemia, Acid-base and electrolyte abnormalities, Malnutrition.

• SepsisSepsisIntra-abdominal sepsis

Wound infection

Septicaemia

3). MalnutritionMalnutrition - Reduced oral intake - Hypercatabolism - Loss of nutrients - Loss of digestive juices - Insufficient absorptive surface

4). Skin irritation & excoriationsSkin irritation & excoriations

5). AnaemiaAnaemia - Malnutrition - Sepsis

- Bleeding

Natural history

Likely to Likely to closeclose

Unlikely to closeUnlikely to close

Anatomic Anatomic locationlocation

Esophageal,Esophageal,

DuodenalDuodenal

stump, jejunalstump, jejunal

Gastric,ilealGastric,ileal

Nutritional Nutritional statusstatus

Well nourishedWell nourished malnourishedmalnourished

SepsisSepsis absentabsent PresentPresent

EtiologyEtiology Appendicitis, Appendicitis, diverticulitis diverticulitis post operativepost operative

Crohn’s, cancer, Crohn’s, cancer, foreign body, foreign body, radiationradiation

Avg. Time to closure 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

• The predominant causes of death are sepsis, electrolyte imbalance, and malnutrition.

CLINICAL PRESENTATIONCLINICAL PRESENTATION

• Recognized 5th-10th days Recognized 5th-10th days post operatively.post operatively.

• Fever

• Leucocytosis

• Prolonged ileus

• Abdominal tenderness

• Drainage of enteric material through the abdominal wound or through or existing drains.

POST OPERATIVE FISTULAPOST OPERATIVE FISTULA

• Localized swelling of the abdominal wall.

• Point tenderness.

• May be – Hypotension– dehydration

CLINICAL PRESENTATIONCLINICAL PRESENTATION

SPONTANEOUS FISTULASPONTANEOUS FISTULA::• INDOLENT MANNER.• FEATURES OF UNDERLYING DISEASE.• INTERNAL FISTULA– PNEUMATURIA, FAECOLURIA.,

DIARRHOEA, VAGUE ABD PAIN.

FACTORS PREVENTING SPONTANEOUS FACTORS PREVENTING SPONTANEOUS CLOSURECLOSURE

• FForeign body in the tract• RRadiation-induced fistula• II nfection/Inflammation

– Active disease at site of fistula– Abscess cavity

• EEpithelialization of the tract• NNeoplasia -Malignancy• DDistal obstruction• Lateral fistula• Bowel wall defect >1cm2

• Fistula tract <2cm long• Fistula site: Lat duodenum, proximal to Lig of treitz , ileal

• 90% of fistulae that will close, do so within 5 weeks of original operation [2][3]

• 50% of fistulae will close spontaneously[3]

• Complex fistulae will undergo spontaneous closure in 1/3 of cases[2]

PRINCIPLES OF MANAGEMENT PRINCIPLES OF MANAGEMENT • AIMAIM

– To restore bowel integrity and continuity

• 3 Stages of care3 Stages of care– Acute – Sub acute – Definitive Repair

• Requires multidisciplinary inputRequires multidisciplinary input• Stoma Nurse/Therapist• Dietician• TPN team• Psychologist/Social work

PRINCIPLES OF MANAGEMENT PRINCIPLES OF MANAGEMENT

SS Stabilization,Sepsis control, Skin/stoma care

NN Nutrition

AA Anatomical Assessment/definition

PP Planned definitive procedure

Principles of Management Fluid Resuscitation and Electrolyte Sepsis Control

• Peritonitis/Drainage/Antibiotics/ Wound Care

Skin Care/Stoma management Gut Management Nutrition

• Oral/enteral/parenteral Anatomical definition

• Understand tract, site• Identify & Mx Contributing/exacerbating

factors Definitive Repair

Acute Phase: Fluid and Electrolytes

• Patients may present malnourished and

dehydrated

• Sepsis, and acutely post op

• Or several prior surgeries, long course

• High fistula output

• Dehydrated and hyponatraemic K, Cl, HCO3

Acute Phase: SepsisAcute Phase: Sepsis

• Commonest cause of death

• Source– anastomotic leakage and collections– fistula effluent– central access

• External Drainage or acute surgery

Acute SurgeryAcute Surgery• Acute intervention is necessary in

– Generalised peritonitis– Cellulitis/ necrotising fasciitis– Collections not amenable to perc drainage– Complete disruption of an anastomosis– Removal of foreign body e.g. mesh– Feeding gastrostomy/jejunostomy

• Acute surgery may have a role in either – excision of fistula or diversion/defunctioning, – if appropriately timed

Acute Phase: Skin careAcute Phase: Skin care

• Skin loss from effluent

• Difficult to manage wounds and stomas

• Monitoring of fistula output

So

• Stoma therapist

• Wound care, Vacuum dressing options

• Good quality nursing care

Acute Phase: Gut Management Acute Phase: Gut Management

• Manipulation of fistula output

• Decreased volume means fewer electrolyte and fluid issues

• Possibly contributes to spontaneous closure

• Contributes to skin care

Fistula Output Fistula Output

• Replace losses with saline

• Rehydrate with electrolytes/glucose

• Medication– Antisecretory

• PPI’s• Somatostatin/Octreotide

– Antimotility• Loperamide/lomotil• Codeine

NUTRITIONNUTRITION

• Malnutrition predicts both mortality and failure of repair

• Multifactorial cause for malnutrition– Chronic illness/ongoing inflammation– Prolonged hospital stay– Loss of nutrients in effluent– High output/short gut

Nutrition ApproachesNutrition Approaches• TPN

– Significant contributor to improved mortality– “Bowel rest” and spontaneous closure– May be only viable option

• Enteral– Advantage for SBP, GIT function,

anastomosis– Elemental feeds– Oral, NGT / fistuloclysis / feeding ostomy /

reinfusion

• Manage deficiencies

• Give adequate calories

ANATOMICAL DEFINITIONANATOMICAL DEFINITION

• Delineate tract

• Origin

• Path

• Length, Width

• Define extent of bowel wall disruption

• Exclude distal obstruction

• Identify Collections

• Etiological disease process

• CT– Fistulogram– Oral and PR contrast

• MRI

• Ba enema

• Endoscopy

PLAN:PLAN: Definitive SurgeryDefinitive Surgery

• OPTIMISE timing (and surgeon)

• OPTIMISE nutrition etc

• OPTIMISE theatre set up

• PLAN strategy

• PLAN for other requirements (blood, stents, other specialties, HDU)

Definitive Surgery: Principles Definitive Surgery: Principles [1][2][1][2]

[3][4][3][4]

• Abdo entry• Via easiest/safest option• Long incision• Upper abdo usu fewer

adhesions• Complete, careful

adhesiolysis• Hydro dissection

technique• Experienced assistant• Repair any serosal tear

or enterotomy as they occur

• Do the easy bit first• Resect fistula and

anastomose bowel if possible

• Consider covering stoma• Interpose omentum• Avoid mesh, settle for a

hernia

SURGICAL TREATMENTSURGICAL TREATMENT

- Preferred op is resection of fistulous segment and tract with end-to-end anastomosis

- Dissection should be minimal and preferably sharp[4]

- Omental patch, proximal colostomy or ileostomy optional

- By-pass or staged operations have no added advantage

- Duodenal fistulae can be closed by truncal vagotomy and gastrojejunostomy

- Rectus abdominis Muscle Flap repair in selected cases

PROGNOSTIC FACTORS[4]

PREDICTORS OF SPONTANEOUS CLOSURE & MORTALITY

Serum levels of short turnover proteins

A. Albumin

B. Retinol binding pre-albumin

C. Thyroxin binding pre-albumin

D. Serum transferrin

PROGNOSTIC FACTORS (CONT)

*If they are low the liver cannot synthesize them and cannot withstand surgery

*Serum transferrin Predictor of spontaneous

closure

Retinol-binding proteinThyroxin-binding prealbumin Predictors of mortality

REHABILITATIONREHABILITATION

• Continued nutrition support

• Zn supplementation

• Psychological/ occupational therapy

PREVENTIONPREVENTION[3][3]

• Identification of high risk individuals.

• Meticulous surgical technique.

COMPLICATIONSCOMPLICATIONS[3][3]

• Anastomotic stricture

• DVT

• Adhesive small bowel obstruction

• Short bowel syndrome

• Recurrence

LITERATURE REVIEW[3]

• 23yr retrospective study of 153 cases treated surgically

• Operative repair mortality– 30 day 4%– 1yr 15%

• Morbidity 80%

• Success @ 1st attempt 70%

• Overall closure rate 84%

CONCLUSIONCONCLUSION[4][4]

• Complex, highly morbid, life threatening condition

• Early recognition & aggressive patient support

• Uncomplicated cases will close spontaneously

• Surgery is usually not an immediate priority except to deal with complications

• Comprehensive multi-disciplinary approach

ReferenceReference

1. Atlas of Intestinal Stomas 2012

2. Schwartz Principles of Surgery 10th Ed 2014

3. Maingot’s Abdominal Operations 11th Ed.

4. Ajao OG, Shehri MY. Enterocutaneous fistula. Saudi J Gastroenterol [serial online] 2001 [cited 2011 Jul 22];7:51-4. Available from: http://www.saudijgastro.com/text.asp?2001/7/2/51/33401

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