ENTERO-CUTANEOUS FISTULA

Dr Sadia Shabbir House Surgeon Surgical unit 1

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

Enterocutaneous fistulas (ECFs) are abnormal communications between the bowel and skin

Morality rate of 6.5 to 21%.

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CLASSIFICATION

Anatomical classification:(1)

Internal: Two organ of same or different system

▪ Enteroenteral, enterovesical,enterocolic,

External: Gut to body surface.

▪ Gastrocutaneous,duodenocutaneous, enterocutaneous.

(2)

Simple or direct.

Complicated-

1.Having multiple tracts

2. Connection with more than one viscus

3. drainage into an associated abscess cavity.

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Physiological classification

High output- output more than 500 ml/ day

Moderate output- output 200-500 ml/day

Low output- output less than 200ml/day

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Etiologic Classification

• Radiation

• Inflammatory bowel disease

• Diverticular disease

• Appendicitis

• Ischaemic bowel disease

• Duodenal ulcer perforation

• Malignancies

• Intestinal tuberculosis

• Actinomycosis.

1. Spontaneous(15-25%)-

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2. Post-operative (75-85%)

• Operations for perforations

• Acute intestinal obstruction

• Intestinal malignancies

• Adhesiolysis

• Blunt and penetrating abdominal trauma

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3. Congenital Tracheo- esophageal Rectovaginal Umbilical fistula.

4. Traumatic Blunt and penetrating trauma of

abdomen, chest and perineum

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ETIOLOGY

Disease bowel extending to surrounding structures

Extraintestinal disease involving otherwise normal bowel

Trauma to normal bowel including inadverent or missed enterotomies

Anostomotic disruption following surgery for a vareity of conditions

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

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

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Factors Influencing

Malnutriton Infection Hypotension Anemia Hypothermia Poor oxygen

delivery

Mobilisation Handling Tension Ischemia hemostasis

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Pathophysiology

Fluid and electrolyte imbalance.

Malnutrition

Sepsis

Skin irritation and excoriation

Clinical presentation

Recognized 5th-10th days post operatively.

Fever

Leucocytosis

Prolonged ileus

Abdominal tenderness

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

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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

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MANAGEMENT

THE GOAL are Re-establishment of bowel continuity Ability to achieve oral nutrition Closure of the fistula

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MANAGEMENT PHASES

PHASE TIME COURSERECOGNITON / STABILISATION

24 TO 48 HRS

INVESTIGATON 7- 10 DAYS

DECISION 10 DAYS TO 6 WEEKS

DEFINITIVE MANAGEMENT

WHEN CLOSURE UNLIKELY OR 4-6 WKS

HEALING 5 – 10 DAYS AFTER CLOSURE UNTILL FULL

ORAL NUTRITON

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Recognition / stabilization

Resuscitation Control of sepsis Electrolyte repletion Control of fistula drainage Local skin care n protection Provision of nutrition

Resuscitation

Restoration of normal circulating blood volume

Correction of electrolyte & acid base imbalance.

Plasma oncotic pressure should be restored by exogenous albumin administration. - 3 mg/dl

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Control of Sepsis

Management of local wound infections

Drainage if Intra-abdominal collections (percutaneous)

Laparotomy may be required for: Extensive cellulitis/necrotising fascitis Incomplete percutaneous drainage of collections Disruption of anastomosis

Antibiotics as per indicated

CVP only after 24 hrs of drainage

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Reduction of fistula output

Restrict hypo-osmolar fluids Encourage electrolyte mix Antisecretory agents

Proton pump inhibitors Somatostatin or octreotide

Antimotility agents Loperamide Codeine

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Somatostatin and analouge

Naturally occuring peptide hormone Inhibitory to gastrointestinal

secrection Plasma half life 1-2 min Mode

Inhibit gastrin n cholecystokinin Reduces splanchic blood flow Reduces rate gastric emptying Inhibit gall bladder contraction

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Skin care management:

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

Goals of skin care: Containing the effluent Patient independence and mobility

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Skin Barriers

Solid wafers (pectin based)

Powders (Pectin / Karaya based)

Paste

Spray and wipes

Ointments and creams (zinc/petroleum based)

Wound pouch dressings

One/two piece design

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Wound pouch dressing

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Nutritional management

Plays Central role in management

Adequate circulation and tissue oxygenation must for optimal utilization.

May be:▪ Enteral ▪ Parenteral

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INVESTIGATION (7-10 days)

Objectives of investigation plan: To define-

Precise anatomical location

Is the bowel in continuity or is disrupted

Abscess cavity

Condition of adjacent bowel

Is there a distal obstruction

Etiological disease process

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Radiological contrast studies

Fistulogram

MRI

Barium transit studies

CT fistulogram

By using water soluble gastrograffin is 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.

bbthapa 30Entero colic fistula Sigmoid cutaneous fistula

Gastro cutaneous fistula

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Endoscopic studies

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

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

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DECISION: (10 days – 6 wks)

No signs of imminent closure after 4- 6 weeks then patient should be prepared for surgery

Uncontrolled sepsis urgent drainage of sepsis.

General condition very poor then only abscess drainage

In case of malignancies early operation should be done.

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DEFINITIVE MANAGEMENT

Optimal nutrition parameters Free of sepsis Well healed abdominal wall without

inflammation Prophylactic antibiotics Tapering of tube feeding Prevent contamination of abdominal wall

tissues Treat the cause

Factors possibly responsible for failure of spontaneous closure are:

a. Foreign Body b. Radiation c. Inflammation/ infection d. Epithelialisation

[F-R-I-E-N-D-S] e. Neoplasm f. Distal intestinal obstruction g. Steroids.