Dr. Tanvir Ahmed &Dr. Suman ParvezIntern doctor, Surgery departmentEnam Medical college Hospital

ENTERO CUTANEOUS FISTULA

Normally, fistula is defined as an abnormal communication between two epithelized surface.But enterocutaneous fistula is an abnormal communication between the skin with various parts of the gut. The ileum is the most common site of origin of enterocutaneous fistula.

Introduction:

A. Pre operative:

1. Previous abdominal surgery2. Malnourished patient3. Surgery for IBD4. Septic patient or acute sepsis5. Steroid use(more than

10gm/dl)6. Intra abdominal abscess

Risk factors:

Perioperative-1. Shock patient2. Extensive adhesiolysis3. Injudicious anastomosis

Post operative:1. Repeat laparotomy

Cont……

A. Anatomical classification: Internal or external fistula- internal fistulae

are named after the structures it communicates like gastrocolic , jejunoileal, aortoenteric fistula

B. Physiological classification:Based on output- High output > 500

ml/day(usually from small gut)Low output- <500 ml/day(usually colonic)

Types or classification of enterocutaneous fistula

Primary or type-1 fistula: It developed as a result of underlying

disease affecting the gut wall.such as….. 1. Neoplasm of gut. 2. Crohn’s disease 3. Ulcerative colitis 4. Intestinal TBSecondary or type-2 fistula: It occurs after injury to otherwise normal

gut.Example: During surgery, Penetrating

trauma,Radiation enteritis

Another classification:

1.Low output fistula ( <500ml/day ) is expected to heal spontaneously, provided there is no distal obstruction.

2. High output fistula(>500 ml/day) is difficult to manage as because less chance of spontaneous heal.

Management :

Overall this management based on well established principle ‘’SNAP’’

S= Stabilization, sepsis control, skin care

N= Nutrition

A= Anatomy of the fistula evaluation

P= Plan to deal with fistula

Management: cont……

Stabilization, sepsis control, skin care:

1. The first step to management is the resuscitation and stabilization of the patient by intravenous fluid, strict input and output measurements are essential and CVP monitoring and urinary catheterization are especially helpful, ongoing fluid loss should be fully replaced and electrolyte imbalances must be corrected.

CONT………

2. Control of sepsis by judicious use of antibiotic

3. Attention should also be given to any intra abdominal / subcutaneous abscesses and if present, they should be drained.

4. Skin protection by vacuum dressing or repeated dressing and in skin damage use zinc oxide paste.

Cont…………….:

Nutrition: Nutritional support needs to begin as soon as the

patient is stabilized. Nutrition can be given by parenteral or enteral route, based on the anatomy of the fistula.

Nutrition via the enteral route is best as because it helps in maintaining the intestinal mucosal barrier, more efficacious delivery of nutrients ,stimulating hepatic protein synthesis.

Cont…….. :

TPN(Total parenteral nutrition is also given in patients who need nutritional support more than 2 weeks or do not tolerate enteral feeds or have long standing ileus or before fistulous tract is well established.

Calorie requirement according to type of fistula, for low output fistula- 30 to 35 kcal/kg/day. For high output 45 to 50 kcal/kg/day and protein 1.5 -2.5 gm/kg/day and twice the daily requirement of vitamins trace elements, zinc.

Cont……… :

Pharmacological agents used to in the management of fistula:

1. Somatostatin analogue octreotide

2. Proton pump inhibitors and H2 receptor antagonists.

continue

To define the anatomy of fistula, stabilization is first needed then investigations to determine the presence and localization of fistula, it’s cause and presence of comorbidities.

Types of imagines are 1. Fistulography ( more common and popular here)2. CT scan of the abdomen with IV and oral

contrast3. MRI4. For small bowel origin- small bowel follow

through contrast study.

Anatomy of the fistula evaluation:

As previous slide I mentioned that low output fistula closed spontaneously. Now the factor responsible for spontaneous closure of fistula:

1. Well nourished patient2. No sepsis3. No distal obstruction4. Tract less than 2 cm.5. Long and narrow tract for the fistula.

Plan to deal with fistula:

Majority (80-90)% will close within 6 weeks with consurvative management.

But in case of faecal fistula or high output fistula or fistula not heal within 6 weeks it is bettre to wait upto 10-12 weeks. In this period patient should be nutritionally optimized, should not be septic and should be vitally stable. Then definitive treatment such as surgery is planned.

Cont…………..:

1. Restoration of intestinal continuity either resection anastomosis or stoma formation.

2. Reconstruction of the abdominal wall defect.

Aim of surgery:

1. Resection of fistulas part then either primary anastomosis or construction of a stoma which may be temporary or permanent

2. For abdominal wall closure, if primary closure not achieved then use mesh to repair or component separation technique.(Ramirez)

Procedure of surgery

1. Daily blood test for S.electrolytes, magnesium

2. Monitoring fistulas output.

3. Urine output.

Monitoring of enterocutaneous fistula patient:

1. Care, meticulous surgery to avoid iatrogenic injury to the gut.

2. Avoid excessive adhesiolysis.

3. Optimize patient condition.

4. Serosal tears should be examined carefully and repaired if required.

Prevention of enterocutaneous fistula :

Majority of the enterocutaneous fistula are due to iatrogenic causes( 70-85)%. So careful during surgery is essential and education about enterocutaneous fistula is important to manage such cases.

Conclusion :

THANK YOU ALL