ENTEROCUTANEOUS FISTULA

DR SONAM TSHERING

Introduction

• Represent catastrophic complications from abdominal diseases and surgical procedures

• Rare, the physiologic challenges to patients, the resources used, and the morbidity and mortality resulting from their occurrence are substantial

• Modern management strategies have resulted in an improved overall mortality from nearly 50% to between 10% and 20%

• Sepsis responsible for the majority of deaths

Classification

Internal or external

• Internal- ileoileal fistulae, ileocolic fistulae, enterovesical or colovesical fistulae, gastrocolic fistulae, enter ovaginal or colovaginal fistulae, and fistulae to the thoracic cavity

External fistulae- communications between the gastrointestinal system and the skin( between two epithelial surface)

Etiology and Prevention

• Extension of bowel abnormalities to surrounding structures

• Extension of adjacent disease to normal bowel• Inadvertent or unrecognized trauma to the bowel• Anastomotic disruption • Seventy to ninety percent of ECFs occur in the

postoperative period • Operations for complications of inflammatory bowel

disease, resection of malignancy, or adhesiolysis forintestinal obstruction are common antecedent procedures

Preoperative factors

• Malnutrition,

• Infection,

• Emergency procedures with concomitant hypotension, anemia, hypothermia, or poor

• oxygen delivery..

Elective procedure(preparation)

• Nutritional support,

• Bowel preparation,

• Control of physiologic parameters such as cardiac output, blood glucose, and anemia

• Serum albumin greater than 3 g/dL

• Patient would have not lost 10% to 15% of body weight

• Diabetes should be controlled

• Correction of anaemia

• Mechanical and antibiotic bowel preparation

• Intravenous antibiotics just prior to incision-decrease the incidence of intra-abdominal and wound infections and abscesses, thus further reducing the likelihood of developing an ECF

Emergency operation(prevention strategy to minimise ECF)

• Optimization of resuscitation

• Performance of a technically meticulous procedure

• Sound surgical technique

• Adequate mobilization

• Use of healthy bowel with good blood supply for anastomosis

• Avoidance of tension

• Prevention of hematoma

• Prior to abdominal closure, the bowel should be inspected for inadvertent bowel injury, and all enterotomies or serosal injuries should be appropriately repaired

Causes of Enterocutaneous Fistulae

Cause Frequency (%)• Postoperative 85• Spontaneous 15• Crohn’s disease 39• Ulcerative colitis 13• Malignancy 9• Radiation 6• Diverticular disease 5• Others 27• Other includes rare conditions such as enteric vasculitis or

myopathy or no associated condition.

Spontaneous ECF

• Inflammation

• Malignancy

• Irradiation

Inflammatory causes

• Crohn’s disease

• Ulcerative colitis

• Peptic ulcer disease

• Appendicitis

• Diverticulitis

• Pancreatitis

• Ischemic bowel

Clinical Presentation

• Recognition- 7 to 10 days following the procedure.

• Slow course with fevers and a prolonged ileus

• Development of wound erythema and, finally, drainage of enteric contents through the wound spontaneously or following opening of the skin over the wound

• Fluid and electrolyte imbalances(low sodium, potassium, phosphate and magnesium)

• Malnutrition

• Sepsis.

Management

Goal

• Restore bowel continuity

• Achieve oral nutrition and

• Close the fistula

Phases of management of ECF

Nutritional Support

• 25 to 32 kcal/kg/d with a calorie-to-nitrogen ratio of 150:1 to 100:1,

• 1.5 g/kg/d of protein

CT fistulogram using water soluble gastrograffinis the investigation of choice

• length and diameter of the tract

• site of bowel wall defect

• health of the adjacent bowel,

• and the presence of strictures

• abscess cavities

• distal obstruction

• anastomotic dehiscence.

Predictors of spontaneous closure

Take home message

Enterocutaneous fistulae may complicate nearly any abdominal surgical procedure during which the bowel integrity is compromised either intentionally or inadvertently. Given the substantial impact of ECFs, an understanding of their cause and prevention as well as their identification and management is important for all surgeons of the peritoneal cavity.