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Management of

Enterocutaneous FistulaP. Bernard McIntyre, M.D.

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Enterocutaneous Fistula Mistakes

Not operating early

enough!

Operating too

early!

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Question 2 There is no need for anyone to wait

greater than 12 weeks for attempt at repair

of enterocutaneous fistula

A. True

B. False

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Question 3

Direct suture repair of exposed fistulas is

futileA. True

B. False

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Etiology

Malignancy

Radiation Crohns Disease

Post-operative ( 80% 90 % )

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Management

Phase 1: Stabilization Phase 2: Anatomical definition

Phase 3: Definitive operation

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Stabilization

Fluid and electrolyte imbalances

Measure fistula losses & electrolyte content if

high output (>500 ml)

Additional HCO replacement may be needed

with duodenal or pancreatic fistulas

H antagonist or PPI

Octreotide may reduce fistula output & shortentime to closure. No evidence to support fistula

closure. May affect immune function.

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Stabilization

Sepsis control

Broad spectrum antibiotics Percutaneous drainage

Laparotomy if needed for source control

Nutrition

Enteral feeding, if feasible (100cm bowel distal orproximal to fistula)

Parenteral feeding may be needed as supplement to

enteral feeds

No level 1 evidence to favor either route

? Fish oil and omega-3 fatty acids

Skin care

The stomal therapist is your friend!

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Enteroatmospheric Fistula

incidence, > 50% mortality

Largely preventable

Avoid negative-pressure or gauze dressings

directly on exposed bowel

Early split-thickness or cadaver skin grafting

to granulating surface

Obliterative peritonitis precludes early repair

(< 6 months)

Effluent control difficult ( avoid tube drainage)

Some success with local suturing and grafting

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VAC System

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Effluent Collecting System

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Anatomical definition

Develop information to assess likelihood of

spontaneous closure (15% - 71%))

Stomach, lateral duodenum, lig. of Treitz,

and distal ileum all unfavorable sites

Fistulograms, contrast studies, CTs may

all play a role in defining anatomy

Wait for established tract (>10 days) for

studies

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Anatomic Features Unfavourable

for Spontaneous Closure

Foreign body

Radiation

Inflammation / Infection

Epithelialization of the tract

Neoplasm Distal obstruction

Short tract or > 1 cm enteral defect

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Definitive operation

Timing is everything!

Shake test Ureteral stenting if expecting dense adhesions

Enter abdominal cavity in easiest area (upper

midline)

Lyse adhesions from stomach to colon

Repair serosal tears and enterotomies as

encountered

Segmental bowel resection of fistula site

Component separation or skin only closure

acceptable . Plastics may need to help

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Extreme

Great

Moderate

Minimal

Time after Operation

Severity of Adhesions

0 7 14 21 28 42 56 84 6 months

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Definitive operation

Timing is everything!

Shake test Ureteral stenting if expecting dense adhesions

Enter abdominal cavity in easiest area (upper

midline) Lyse adhesions from stomach to colon

Repair serosal tears and enterotomies as

encountered

Segmental bowel resection of fistula site

Component separation or skin only closure

acceptable . Plastics may need to help.

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Conclusions

ECF remains a difficult management

problem, especially EAF

The basis of management remains control

of sepsis and fistula effluent with ongoing

nutritional maintenance

Early surgery should be limited to abscess

drainage and proximal defunctioning

stoma

Definitive procedures for persistent ECF

should take place several months later

with resection of the fistulous segment