Dr. Onkar Singh

Department of surgery

MY Hospital & MGM Medical College,

Indore M.P.

• A A FistulaFistula is defined as an abnormal is defined as an abnormal communication between two communication between two epithelized surfaces.epithelized surfaces.

HISTORYHISTORY• The earliest record of an enterocutaneous The earliest record of an enterocutaneous

Fistula appears in the old Testament Book of Fistula appears in the old Testament Book of judges Written BY judges Written BY SamuelSamuel Between 1043 BC Between 1043 BC and 1004 BC.and 1004 BC.

• CelsusCelsus described the first reported attempt of described the first reported attempt of surgical repair of a colocutaneous fistula.surgical repair of a colocutaneous fistula.

• In the 18In the 18thth century century John HunterJohn Hunter advocated a advocated a conservative approach to fistulas after he conservative approach to fistulas after he noted that fistulas occasionally close noted that fistulas occasionally close spontaneously.spontaneously.

•In early 1900’s enterostomy was made in healthy bowel proximally in obstructed bowel

•This often would close spontaneously on resolution of obstruction

•This lead to an unrealistic optimistic approach towards all enterocutaneous fistulas

CLASSIFICATIONCLASSIFICATION

Anatomical classification:Anatomical classification:

• (1) a. (1) a. Internal:Internal: Two organ of same or different systemTwo organ of same or different system

• Enteroenteral, enterovesical,enterocolic, colovesicalEnteroenteral, enterovesical,enterocolic, colovesical

b. b. ExternalExternal: Gut to body surface.: Gut to body surface.• Gastrocutaneous,duodenocutaneous, enterocutaneous.Gastrocutaneous,duodenocutaneous, enterocutaneous.

• (2) a. (2) a. Simple or direct.Simple or direct.

b. b. ComplicatedComplicated- - • 1.Having multiple tracts 1.Having multiple tracts

• 2. Connection with more than one viscus 2. Connection with more than one viscus

• 3. drainage into an associated abscess cavity.3. drainage into an associated abscess cavity.

Physiological classificationPhysiological classification

• High outputHigh output- output more than 500 ml/ - output more than 500 ml/ dayday

• Moderate outputModerate output- output 200-500 - output 200-500 ml/dayml/day

• Low outputLow output- output less than - output less than 200ml/day200ml/day

Etiologic ClassificationEtiologic Classification

• RadiationRadiation

• Inflammatory bowel Inflammatory bowel diseasedisease

• Diverticular diseaseDiverticular disease

• AppendicitisAppendicitis

• Ischaemic bowel Ischaemic bowel diseasedisease

• Duodenal ulcer Duodenal ulcer perforationperforation

• MalignanciesMalignancies

• Intestinal tuberculosisIntestinal tuberculosis

• Actinomycosis.Actinomycosis.

• SpontaneousSpontaneous(15-25%)-(15-25%)-

2. Post-operative2. Post-operative (75-85%) (75-85%)

• Operations for Operations for perforationsperforations

• Acute intestinal Acute intestinal obstructionobstruction

• Intestinal Intestinal malignanciesmalignancies

• AdhesiolysisAdhesiolysis

• Blunt and Blunt and penetrating penetrating abdominal trauma.abdominal trauma.

3. 3. CongenitalCongenital– Tracheo- esophagealTracheo- esophageal– RectovaginalRectovaginal– Umbilical fistula.Umbilical fistula.

4. 4. TraumaticTraumatic – Blunt and penetrating trauma of Blunt and penetrating trauma of

abdomen, chest and perineumabdomen, chest and perineum

ETIOLOGYETIOLOGY

• Extension of bowel abnormalities to Extension of bowel abnormalities to surrounding structures.surrounding structures.

• Extension of adjacent disease to normal Extension of adjacent disease to normal bowelbowel

• Inadvertent or unrecognized trauma to the Inadvertent or unrecognized trauma to the bowel.bowel.

• Anastomotic disruptionAnastomotic disruption..

• Small intestinal fistula are most Small intestinal fistula are most common type of gastrointestinal common type of gastrointestinal fistulas encountered.fistulas encountered.

• Most series report 70%-90-% of Most series report 70%-90-% of small intestinal fistulas occurs after small intestinal fistulas occurs after an operative procedure.an operative procedure.

• The operations commonly causing The operations commonly causing small intestinal fistulassmall intestinal fistulas – Operation for malignancy, Operation for malignancy, – Inflammatory bowel diseaseInflammatory bowel disease– Adhesiolysis.Adhesiolysis.

• The different complications leading to The different complications leading to fistula formation includefistula formation include– Disruption of an anastomosis,Disruption of an anastomosis,– Unrecognized injury to the bowel at the Unrecognized injury to the bowel at the

time of lysis of adhesions time of lysis of adhesions – Inadvertent suture of the bowel at the Inadvertent suture of the bowel at the

time of abdominal closures.time of abdominal closures.

• Fistula may result from anastomosis Fistula may result from anastomosis done in unprepared bowel or in a done in unprepared bowel or in a bowel with less than adequate blood bowel with less than adequate blood supply.supply.

• Anastomosis may also be jeopardized Anastomosis may also be jeopardized by hypotension owing to inadequate by hypotension owing to inadequate resuscitation or by resuscitation or by excess tension excess tension placed on the suture linesplaced on the suture lines

• Poor nutritional status contributes to Poor nutritional status contributes to anastomotic breakdown.anastomotic breakdown.

PathophysiologyPathophysiology

• Fluid and electrolyte imbalance.Fluid and electrolyte imbalance.

• MalnutritionMalnutrition

• Sepsis Sepsis

• Skin irritation and excoriationSkin irritation and excoriation

Natural history

PresentabsentSepsis

Crohn’s, cancer, foreign body, radiation

Appendicitis, diverticulitis post operative

Etiology

malnourishedWell nourishedNutritional status

Gastric,ilealEsophageal,Duodenalstump, jejunal

Anatomic location

Unlikely to closeLikely to close

Unlikely to closeLikely to close

<200mg/dl>200mg/dltransferrin

epithelizationTract >2 cm Defect < 1cm2

miscellaneous

Total disruption,abscess,total obstruction, active disease.

Healthy adjacent tissue, small leak,quiescence disease, no abscess.

Condition of bowel

Avg. Time to closure Avg. Time to closure

• Varies with anatomical locationVaries with anatomical location;;

3.3. Esophageal- 15-25 daysEsophageal- 15-25 days

5.5. Duodenal- 30-40 daysDuodenal- 30-40 days

7.7. Colonic - 30- 40 daysColonic - 30- 40 days

9.9. Small Bowel- 40-60 daysSmall Bowel- 40-60 days

Clinical presentationClinical presentation

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

• FeverFever

• LeucocytosisLeucocytosis

• Prolonged ileusProlonged ileus

• Abdominal tendernessAbdominal tenderness

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

• Localized swelling Localized swelling of the abdominal of the abdominal wall.wall.

• Point tenderness.Point tenderness.

• May be May be – HypotensionHypotension– dehydration dehydration

• Decreased peripheral Decreased peripheral vascular resistance vascular resistance

InvestigationsInvestigationsObjectives of investigation plan: To define-Objectives of investigation plan: To define-

• Precise anatomical locationPrecise anatomical location

• Is the bowel in continuity or is disruptedIs the bowel in continuity or is disrupted

• Abscess cavityAbscess cavity

• Condition of adjacent bowelCondition of adjacent bowel

• Is there a distal obstructionIs there a distal obstruction

• Etiological disease processEtiological disease process

Radiological contrast studiesRadiological contrast studies

• Fistulography :Fistulography : A water soluble contrast A water soluble contrast material is injected into the fistula tract through material is injected into the fistula tract through a 5 or 8 size pediatric tube and it is observed a 5 or 8 size pediatric tube and it is observed fluoroscopically or through static radiological fluoroscopically or through static radiological films.films.

• Barium transit studiesBarium transit studies : Barium meal : Barium meal follow through & barium enemas.follow through & barium enemas.

FISTULOGRAM

Entero-colic fistula

CT- Scan

Entero colic fistula Sigmoid cutaneous fistula

Gastro cutaneous fistula

Endoscopic studiesEndoscopic studies

• Gastro duodenoscopyGastro duodenoscopy : Demonstrates both : Demonstrates both underlying disease and presence of fistula.underlying disease and presence of fistula.

• ColonoscopyColonoscopy : : Fistula is usually not visible but Fistula is usually not visible but presence of disease and its nature by biopsy can presence of disease and its nature by biopsy can be demonstrated.be demonstrated.

• CT scanCT scan : : To evaluate the abdomen for To evaluate the abdomen for presence of abscess in an aseptic patient. presence of abscess in an aseptic patient.

Colonoscopy

Management phases for Management phases for gastro intestinal fistulasgastro intestinal fistulas

5-10 days after closure

5. Healing

When spontaneous closure is unlikely or after 4-6 wks.

4. Definitive therapy

7-10 days to 4-6 wks.3. Decision

After 7-10 days2. Investigation

Within 24-48 hrs.1. Stabilization

StabilizationStabilization

• RehydrationRehydration

• Correction of Correction of anaemiaanaemia

• Drainage of sepsisDrainage of sepsis

• Electrolyte Electrolyte repletionrepletion

• Osmotic pressure Osmotic pressure restorationrestoration

• Nutrition support Nutrition support

• Control of fistula Control of fistula drainagedrainage

• Institution of local skin Institution of local skin carecare

StabilizationStabilization

• Resuscitation Resuscitation ::

– Restoration of normal circulating blood volume.Restoration of normal circulating blood volume.

– Correction of electrolyte & acid base imbalance.Correction of electrolyte & acid base imbalance.

– Plasma oncotic pressure should be restored by Plasma oncotic pressure should be restored by exogenous albumin administration. exogenous albumin administration.

• Nasogastric tubesNasogastric tubes : should be : should be removed if removed if

– There is a no obstruction.There is a no obstruction.

– Fistula is a low in intestinal tract.Fistula is a low in intestinal tract.

Skin care management:Skin care management:

• Problems in skin around the fistula:Problems in skin around the fistula:– Wetness Wetness – Burning pain Burning pain – Discomfort from skin edemaDiscomfort from skin edema

• Goals of skin care:Goals of skin care:– Containing the effluentContaining the effluent– Patient independence and mobilityPatient independence and mobility

T

Techniques of skin care:Techniques of skin care:

• Wound pouch dressingsWound pouch dressings

– One/two piece designOne/two piece design

– Clip closure or Urostomy typeClip closure or Urostomy type

– May be attached to a bed side bag or suction May be attached to a bed side bag or suction catheter catheter

Wound pouch dressing

• Skin Barriers:Skin Barriers:

– Solid wafers (pectin based)Solid wafers (pectin based)

– Powders (Pectin / Karaya based)Powders (Pectin / Karaya based)

– Paste Paste

– Spray and wipesSpray and wipes

– Ointments and creams (zinc/petroleum Ointments and creams (zinc/petroleum based)based)

• Sump Drainage:Sump Drainage:

– For fistulae draining with open abdominal wound.For fistulae draining with open abdominal wound.

– Large bore drains or sumpsLarge bore drains or sumps

– High pressure suction (better results).High pressure suction (better results).

• Nutritional management:Nutritional management:– Plays Central role in managementPlays Central role in management

– Adequate circulation and tissue oxygenation Adequate circulation and tissue oxygenation must for optimal utilization.must for optimal utilization.

– May be:May be:• Enteral Enteral

• Parenteral Parenteral

Central line

10mg/wk10mg/wkVitamin K

Close watchUsually not needed

Minerals

2RDAVit C – 5 –10RDA

RDAVit C – 2RDA

Vitamins

Parenteral (20-30%)

Enteral (20-30%)

LipidsBEE x 1.5BEECalories

1.5-2.5g/kg/day1-1.5g/kg/day

ProteinUsually Parenteral Enteral Form High OutputLow Output

Recommended Nutritional Support

•Chapman and colleagues demonstrated that patients receiving optimal nutritional support (3000 calories per day) had a mortality rate of 12% as compared to 55% mortality among patients receiving a sub optimal nutritional regimen.

•Robauk and Nichdoff reported closure of 73% enteric fistulae in patients with adequate caloric supplementation but only 19% healed when nutritional support was inadequate.

• Patients should receive Patients should receive 3000 to 5000 3000 to 5000 non proteins calories per daynon proteins calories per day

• Amino acid 100 to 200 gm.Amino acid 100 to 200 gm.

• TPN should initiate early in the TPN should initiate early in the course of treatment while adynamic course of treatment while adynamic ileus persist and before the fistula ileus persist and before the fistula tract is well established. tract is well established.

• Patients Patients daily protein requirementdaily protein requirement is is 1.2 to 2.0 gm kg/day.1.2 to 2.0 gm kg/day.

• Fluid requirementFluid requirement is 30ml/kg/day. is 30ml/kg/day.

• Electrolyte requirement/dayElectrolyte requirement/day

• Na-70-100 meq/dayNa-70-100 meq/day

• K- 70-100 meq/dayK- 70-100 meq/day

• Mg- 15-20 meq/day Mg- 15-20 meq/day

• Ca- 10-20 meq/dayCa- 10-20 meq/day

Total Parenteral NutritionTotal Parenteral Nutrition• Conc. dextroseConc. dextrose: 500ml of 20% Dex. (=400 : 500ml of 20% Dex. (=400

kcal)kcal)

• FatFat: 500 ml 10% fat emulsion (=450 kcal): 500 ml 10% fat emulsion (=450 kcal)

• Crystalline Amino AcidsCrystalline Amino Acids: 500 ml 10% : 500 ml 10% Amino acids (=8.4 g Nitrogen)Amino acids (=8.4 g Nitrogen)

• Daily Vitamin SupplementationDaily Vitamin Supplementation ( Vit. K 10 ( Vit. K 10 mg weekly)mg weekly)

AdministrationAdministration::

• Central Line:Central Line:– Subclavian VeinSubclavian Vein– Internal Jugular VeinInternal Jugular Vein

• Peripheral linePeripheral line

Rate of Infusion:

•Starting: 50 – 100 ml/hr•Gradually increased by 25 – 50 ml/hr every second day

Patient Monitoring:Patient Monitoring:

• Clinically: Clinically: (daily)(daily)– Sense of well beingSense of well being– Graded activityGraded activity– VitalsVitals– Weight / input-outputWeight / input-output

• Laboratory profile: Laboratory profile: (daily until patient stable then (daily until patient stable then twice weekly)twice weekly)– Serum ElectrolytesSerum Electrolytes– RFTRFT– LFT/ coagulation profileLFT/ coagulation profile– Lipid profileLipid profile

Complications of TPNComplications of TPN

• MechanicalMechanical– Catheter tip malposition (6%)Catheter tip malposition (6%)– Arterial laceration (1.4%)Arterial laceration (1.4%)– Hydro-pneumo-haemo thorax (1.1%)Hydro-pneumo-haemo thorax (1.1%)– Subclavian/Superior vena cava thrombosis Subclavian/Superior vena cava thrombosis

(0.3%)(0.3%)– Thrombophlebitis (0.1%)Thrombophlebitis (0.1%)– Catheter embolism (0.1%)Catheter embolism (0.1%)

• Septic Septic – Catheter related sepsis Catheter related sepsis (7.4%)(7.4%)

• MetabolicMetabolic – AcuteAcute

• Hyperglycemia/hypoglycemiaHyperglycemia/hypoglycemia

• Electrolyte abnormalitiesElectrolyte abnormalities

• Fluid overloadFluid overload

• HyperlipidemiaHyperlipidemia

– Chronic Chronic • Metabolic bone diseaseMetabolic bone disease

• Alterations in bile compositionAlterations in bile composition

Enteral NutritionEnteral Nutrition

• Benefits:Benefits:– Trophic effect on bowelTrophic effect on bowel– Stimulates hepatic protein synthesisStimulates hepatic protein synthesis

• 4 ft of functional bowel required (proximal or 4 ft of functional bowel required (proximal or distal)distal)

• Lipid based formula absorbed more efficientlyLipid based formula absorbed more efficiently

Control of SepsisControl of Sepsis

• Management of local wound infectionsManagement of local wound infections

• Drainage if Intra-abdominal collections Drainage if Intra-abdominal collections (percutaneous)(percutaneous)

• Laparotomy may be required for:Laparotomy may be required for:– Extensive cellulitis/necrotising fascitisExtensive cellulitis/necrotising fascitis– Incomplete percutaneous drainage of collectionsIncomplete percutaneous drainage of collections– Disruption of anastomosisDisruption of anastomosis

AntibioticsAntibiotics • To be withheld unless the patient is septicTo be withheld unless the patient is septic

Measures to decrease secretionsMeasures to decrease secretions

•Shortens time to closure ( no role in spontaneous closure)

•H2 antagonists/ Proton pump inhibitors

•Somatostatin / octreotide

•Infliximab (monoclonal antibody) (in Crohn’s disese)

•Oral tacrolimus (in Crohn’s disese)

Emotional supportEmotional support

• External drainage of enteric contents can External drainage of enteric contents can be demoralizingbe demoralizing

• Psychiatric evaluation and use of Psychiatric evaluation and use of antidepressant drugs antidepressant drugs

• Reassurance Reassurance

DECISION:DECISION:

• No signs of imminent closure after 4- 5 weeksNo signs of imminent closure after 4- 5 weeks then patient should be prepared for surgery.then patient should be prepared for surgery.

• Unfavorable characteristics since beginningUnfavorable characteristics since beginning

• Uncontrolled sepsis urgent drainage of sepsis.Uncontrolled sepsis urgent drainage of sepsis.

• If patient general condition very poor then only If patient general condition very poor then only abscess drainage should be done .abscess drainage should be done .

• In case of malignancies early operation should In case of malignancies early operation should be done.be done.

TreatmentTreatment • Patient should be amply resuscitatedPatient should be amply resuscitated

• Drainage culturedDrainage cultured

• Intraluminal and intravenous antibioticIntraluminal and intravenous antibiotic

• Discontinuation enteral nutrition 1-2 day prior while Discontinuation enteral nutrition 1-2 day prior while continuing parenteral nutritioncontinuing parenteral nutrition

• Operative approach preferably through a Operative approach preferably through a new new incisionincision

• Best results are with Best results are with definitive resection and end-to-definitive resection and end-to-end anastomosis end anastomosis

• Protective diverting stoma proximal to Protective diverting stoma proximal to anastomosisanastomosis

• Secure closure of abdominal wall over the Secure closure of abdominal wall over the fistulafistula

• Post-op nasogastric decompressionPost-op nasogastric decompression

• Feeding jejunostomy ( for proximal Feeding jejunostomy ( for proximal fistulae) fistulae)

• Post op continuation of nutrition with Post op continuation of nutrition with gradual shift from parenteral to enteral gradual shift from parenteral to enteral formform

Operative procedure of fistula

Operated case of enterocutaneous fistula

Late ComplicationsLate Complications::

• Short bowel syndrome (after multiple Short bowel syndrome (after multiple fistula repair)fistula repair)

• Stricture and partial obstruction at fistula Stricture and partial obstruction at fistula sitesite

• Esophageal stricture after prolonged Esophageal stricture after prolonged nasogastric sump decompressionnasogastric sump decompression

Prevention of Fistula:Prevention of Fistula:

• Prophylactic Antibiotics and Bowel Prophylactic Antibiotics and Bowel Preparation:Preparation:

– Polythelene glycolPolythelene glycol administrtion decreases administrtion decreases bacterial load from 10 bacterial load from 10 12-15 12-15 to 10 to 10 4-54-5

– Enteral non-absorbable antibiotics reduce it to Enteral non-absorbable antibiotics reduce it to 10 10 2-32-3

– Prophylactic I/v antibiotic at time of induction Prophylactic I/v antibiotic at time of induction of anaesthesia with repetition of dose in case of anaesthesia with repetition of dose in case of prolonged surgeryof prolonged surgery

– Post op continuation of antibioticPost op continuation of antibiotic

• Appropriate hydration to prevent Hypotension and Appropriate hydration to prevent Hypotension and compromised circulationcompromised circulation

• Anastomosis in healthy bowel with adequate blood Anastomosis in healthy bowel with adequate blood supply; supply; without tensionwithout tension

• Meticulous and precise hemostasisMeticulous and precise hemostasis

• Selection of proper needle size,suture Selection of proper needle size,suture

• Omental covering if possibleOmental covering if possible

• Dead space obliterated with live tissue and properly Dead space obliterated with live tissue and properly draineddrained

• Drains kept away from anastomosis siteDrains kept away from anastomosis site

Decision makingDecision making• Adequate duodenal mobilization in case of Adequate duodenal mobilization in case of

gastroduodenal anastomosisgastroduodenal anastomosis

• Tube duodenostomy to prevent duodenal stump Tube duodenostomy to prevent duodenal stump blow outblow out

• In multiple typhoid perforations resection of In multiple typhoid perforations resection of diseased segment and end to end anastomosis is diseased segment and end to end anastomosis is better than primary repairbetter than primary repair

• Small bowel defects greater than half the Small bowel defects greater than half the circumference should be treated by resection and circumference should be treated by resection and anastomosisanastomosis

• Proximal diverting stoma should be contemplated Proximal diverting stoma should be contemplated in case of gross contamination. in case of gross contamination.

•

• Stomas with mucus fistula or exteriorization to be Stomas with mucus fistula or exteriorization to be considered in medically unfit or aged patientsconsidered in medically unfit or aged patients

• Proper proximal decompression while doing Proper proximal decompression while doing

anastomosisanastomosis. .

HEALINGHEALING • In the postoperative period, it is necessary to ensure In the postoperative period, it is necessary to ensure

that the patient continues to receive full nutritional that the patient continues to receive full nutritional support. support.

• Adequate protein and calories must be provided to Adequate protein and calories must be provided to maximize healing and minimize complications. maximize healing and minimize complications.

• Although enteral nutrition may be attempted early in Although enteral nutrition may be attempted early in the post-operative course, it is nearly impossible to the post-operative course, it is nearly impossible to meet the patient's entire nutritional demand by this meet the patient's entire nutritional demand by this route. route.

• Postoperative care will most likely include parenteral Postoperative care will most likely include parenteral and enteral supplementation in an overlapping and enteral supplementation in an overlapping manner.manner.

• After fistula closure, whether by After fistula closure, whether by spontaneous or surgical means, the patient spontaneous or surgical means, the patient will need to resume oral intake. will need to resume oral intake.

• This may be especially difficult in an This may be especially difficult in an individual who has had little or no oral individual who has had little or no oral intake for 4 to 6 weeks or more, and intake for 4 to 6 weeks or more, and enlisting the assistance of a dietician and enlisting the assistance of a dietician and the patient's family is often helpful. the patient's family is often helpful.