Anda di halaman 1dari 111

By using our site you agree to our Cookies Policy

Don't show again for 30 days

Log InRegister
 Most Popular
 Study
 Business
 Design
 Data & Analytics
 Hi-Technology
 Explore all categories

LP FISTEL ENTEROKUTAN
 Home
 Documents
 LP fistel enterokutan

1
Konsep Dasar
Fistel Enteroku
taneus
A.
DefinisiFistel
berarti
adanya
hubungan
abnormal
antara ruang
yang satu
dengan
ruangyang
lainnya. Jadi
Fistel
enterokutane
us adalah
celah atau
saluran
abnormalant
ara usus
dengan kulit
abdomen.
Berdasarkan
atas
hubungan de
ngan
dunialuar,
maka fistel
dibagi
menjadi 2
bagian yaitu
fistel
external dan
fistelinternal.
Fistel
eksternal
dimaksudkan
pada fistel
yang
salurannyam
enghubungk
an antara
organ dalam
tubuh
dengan
dunia luar,
contohnya
fistelenterok
utaneus,
fistel
umbilikalis.
Sedangkan
fistel internal
adalah fistel
yngmenghub
ungkan dua
bagian tubuh
yang kedua-
duanya
masih
berada
dalamtubuh,
contohnya
fistel
vesicorectal,
fistel
rektovaginal,
fistel
vesikokolik (
Brunner &
Suddarth,
2002)B.
EtiologiBerda
sarkan atas
penyebabny
a, maka fistel
dikelompokk
an menjadi
tigabagian y
aitu :1.
Congenital ; j
enis fistel
ini terbentuk
sejak lahir,
contohnya fis
telduodenoc
olic.2.
Spontan :
jenis fistel ini
biasanya
terbentuk
sebagai hasil
perjalanan
kronissuatu
penyakit.
Penyakit
yang bisa
menimbulka
n fistel yakni
Chrowndisea
se, TB ,
divertikel,
abses,
perforasi
local, radiasi
dan
enteritis.3.

Aquaired/
didapat :
fistel ini
terbentuk
karena
kesalahan
dalam
tindakanpem
bedahan
misalnya
dalam
operasi
anastomosis,
drainase
abses.C.

PatofisiologiS
alah satu
penyebab
terbentuknya
fistel
enterokutane
us adalah
chrowndisea
se. Pada
penyakit
Chrown,
terjadi
inflamasi
kronis dan
subakut
yangmeluas
ke seluruh
lapisan
dinding usus
dari mukosa
usus, ini
disebut
jugatransmur
al.
Pembentuka
n
fistula,fisura
dan abases
terjadi terjadi
sesuai
2
luasnya
inflamasi ke
dalam
peritoneum.
Jika proses
inflamasi
terus
berlanjutmak
a saluran
abnormal
yang
terbentuk
bisa
mencapai
kutan (kulit)
abdomenseh
ingga
terbentuklah
fistel
enterokutane
us. Lesi
(ulkus) tidak
pada
kontak terus-
menerus
satu sama
lain dan
dipisahkan
oleh jaringan
normal. Pada
kasuslanjut,
mukosa usus
mengalami
penebalan
dan menjadi
fibrotic dan
akhirnyalum
en usus
menyempit
(Brunner &
Suddarth,
2002).D.
Manifestasi
Klinik Penye
mpitan
lumen usus
tadi
mempengaru
hi
kemampuan
usus
untuk mentr
anspor
produk dari
pencernaan
usus atas
melalui
lumen
terkonstriksi
dan akhirnya
mengakibatk
an nyeri
abdomen
berupa kram.
Karena
peristalticusu
s dirangsang
oleh
makana,
maka nyeri
biasanya
timbul
setelah
makan.Untuk
menghindari
nyeri ini,
maka
sebagian
pasien
cenderung
untuk memb
atasi
masukan
makanan,
mengurangi
jumlah dan
jenis
makanansehi
ngga
kebutuhan
nutrisi
normal tidak
terpenuhi.
Akibatnya
penurunanbe
rat badan,
malnutrisi,
dan anemia
sekunder
(Brunner &
Suddarth,
2002).Selain
itu,
pembentuka
n ulkus di
lapisan
membrane
usus dan
ditempatterj
adinya
inflamasi,
akan
menghasilka
n rabas
pengiritasi
konstan
yangdialirkan
ke kolon dari
usus yang
tipis,
bengkak,
yang
menyebabka
n
diarekronis.
Kekurangan
nutria juga
bisa terjadi
karena
gangguan
pada
absorbs.Akib
anya adalah
individu
menjadi
kurus karena
masukan
makanan
tidak adekua
t dan cairan
hilang secara
terusmeneru
s. Pada
beberapa
pasien,
ususyang
terinflamasi
dapat
mengalami
demam dan
leukositosis
(Brunner
&Suddarth,
2002).E.
Pemeriksaan
PenunjangDe
ngan
penggunaan
CT scan dan
MRI, maka
dapat
menunjukka
n
adanyapene
balan
dinding usus
dan fistula
saluran.
Hitung darah
dapat
dilakukanunt
uk mengkaji
hematokrit
dan kadar
hemoglobin
yang
biasanya
menurunsert
a
hitung sel da
rah
putih yang bi
asanya
mengalami p
eningkatan.
laju
3
sedimentasi
biasanya aka
n meningkat.
Kadar albumi
n dan protein
jugamengala
mi
penurunan.
Penurunan
nilai albumin
dan protein
ini dapat
menjadiindic
ator
pertanda
malnutrisi
(Brunner &
Suddarth,
2002).F.
Penatalaksan
aanTindakan
medis
ditujukan
untuk
mengurangi
inflamasi,
menekan
respon
imundan
mengistiraha
tkan usus
yang sakit.
Untuk
mengatasi
masalah
gangguannut
risi, maka
dapat
diberikan
cairan oral,
diet rendah
residu, tinggi
proteintinggi
kalori dan
terapi
suplemen
vitamin
pengganti
besi.
Ketidakseimb
angancairan
dan elektrolit
yang
dihubungkan
dengan
dehidrasi
akibat diare,
diatasidenga
n terapi
intravena
sesuai
kebutuhan.
Sedangkan
untuk terapi
obat-obatan,
diberikan
sedative dan
antidiare/
antiperistalti
k. Hal ini
diberikanunt
uk
mengistiraha
tkan usus
yang
terinflamasi.
Terapi ini
dilanjutkan
sampaifreku
ensi defekasi
dan
konsistensi
feses pasien
mendekati
normal.
Selain
itudiberikan
pula
antibiotuk
untuk
mengatasi
infksi
sekunder
dan
pemberianob
at-obatan
anti inflamasi
(Brunner &
Suddarth,
2002).
ASUHAN
KEPERAWAT
AN/ASKEP
A.
Pengkajian
Keperawatan
Riwayat
kesehatan
diambil
untuk
mengidentifi
kasi awitan,
durasi
dankarakteri
stik nyeri
abdomen,
adanya diare
atau
dorongan
fekal,
mual,anorek
sia atau
penurunan
berat badan
dan riwayat
keluarga
tentang
penyakitusus
inflamasi.
Pengkajian
pola
eliminasi
usus
mencakup
karakter,
frekuensidan
adanya
darah, pus,
lemak, atau
mucus.
Alergi
penting
untuk
dokumnetasi,
khususnya
intoleransi
usus atau
lactose.
Pasien
menunjukka
n gangguan
polatidur bila
diare atau
nyeri terjadi
padamalam
hari.Pengkaji
an objektif
mencakup
auskultasi
abdomen
terhadap
bising usus
dankarakteri
stiknya,
palpasi
abdomen
terhadap
distensi,
nyeri tekan,
atau
nyeridan
inspeksi kulit
terhadap
bukti adanya
saluran
fistula atau
gejala
dehidrasi.
4
Feses di
inspeksi
terhadap
adanya
darah dan
mucus.
Gejala paling
utamaadalah
nyeri
intermitten
yang terjadi
pada diare
tetapi tidak
hilang
setelahdefek
asi. Nyeri
pada daerah
periumbilikal
biasanya
menunjukka
n
keterlibatanil
eum
terminalis
(Brunner &
Suddarth,
2002).B.
Diagnosa
Keperawatan
Diagnosa
keperawatan
utama
mencakup (D
oengoes
Marylynn,
2002):1.

Perubahan
nutrisi,
kurang dari
kebutuhan
tubuh
berhubungan
denganpemb
atasna diet,
mual dan
malabsorbsi.
2.
Nyeri
abdomen
berhubungan
dengan
peningkatan
peristaltic
dan
inflamasi3.
Kurang
volume
cairan dan
elektrolit
berhubungan
dengan
anoreksia
mualdan
diare4.

Perubahan
suhu tubuh :
hipertermia
berhubungan
dengan
inflamasi.5.

Gangguan
pola tidur
berhubungan
dengan
demam dan
nyeriC.

Intervensi
Keperawatan
Diagnosa I :
Perubahan
nutrisi,
kurang dari
kebutuhan
tubuh
berhubungan
dengan
pembatasan
diet, mual
dan
malabsorbsi.I
ntervensi
(Wilkinson,
2007):1.

Kaji pola
makan
klien.2.
Buat jadwal
masukan
tiap jam.
Anjurkan
cairan /
makanan
dan
minumsediki
t demi
sedikit.3.

Beri
makanan
yang
bervariasi.4.
Anjurkan
klien untuk
makan
makanan
lunak
dengan porsi
sedikit
tapisering.5.

Mengukur BB
tiap hari
dengan
timbangan
yang
sama.6.

Berikan
Health Education
tentang
pentingnya
nutrisi.7.
Pantau
status nutrisi
melalui nilai
laboratorium
khususnya
albumin dan
Hb8.
Kolaborasika
n dengan
ahli gizi
dalam
menentukan
kebutuhan
proteinuntuk
klien. prev
next

out of 6

Post on 15-Jul-2015
856 views
Category:

Documents
36 download
Report
 Download
FacebookTwitterGoogle+EmailLagi...
TRANSCRIPT

Konsep Dasar Fistel Enterokutaneus A. Definisi Fistel berarti adanya


hubungan abnormal antara ruang yang satu dengan ruang yang lainnya.
Jadi Fistel enterokutaneus adalah celah atau saluran abnormal antara usus
dengan kulit abdomen. Berdasarkan atas hubungan dengan dunia luar,
maka fistel dibagi menjadi 2 bagian yaitu fistel external dan fistel internal.
Fistel eksternal dimaksudkan pada fistel yang salurannya menghubungkan
antara organ dalam tubuh dengan dunia luar, contohnya fistel
enterokutaneus, fistel umbilikalis. Sedangkan fistel internal adalah fistel
yng menghubungkan dua bagian tubuh yang kedua-duanya masih berada
dalam tubuh, contohnya fistel vesicorectal, fistel rektovaginal, fistel
vesikokolik (Brunner & Suddarth, 2002) B. Etiologi Berdasarkan atas
penyebabnya, maka fistel dikelompokkan menjadi tiga bagian yaitu : 1.
Congenital duodenocolic. 2. Spontan : jenis fistel ini biasanya terbentuk
sebagai hasil perjalanan kronis suatu penyakit. Penyakit yang bisa
menimbulkan fistel yakni Chrown disease, TB , divertikel, abses, perforasi
local, radiasi dan enteritis. 3. Aquaired/ didapat : fistel ini terbentuk
karena kesalahan dalam tindakan pembedahan misalnya dalam operasi
anastomosis, drainase abses. C. Patofisiologi Salah satu penyebab
terbentuknya fistel enterokutaneus adalah chrown disease. Pada penyakit
Chrown, terjadi inflamasi kronis dan subakut yang meluas ke seluruh
lapisan dinding usus dari mukosa usus, ini disebut juga transmural.
Pembentukan fistula,fisura dan abases terjadi terjadi sesuai ; jenis fistel ini
terbentuk sejak lahir, contohnya fistel 1 luasnya inflamasi ke dalam
peritoneum. Jika proses inflamasi terus berlanjut maka saluran abnormal
yang terbentuk bisa mencapai kutan (kulit) abdomen sehingga
terbentuklah fistel enterokutaneus. Lesi (ulkus) tidak pada kontak terus-
menerus satu sama lain dan dipisahkan oleh jaringan normal. Pada kasus
lanjut, mukosa usus mengalami penebalan dan menjadi fibrotic dan
akhirnya lumen usus menyempit (Brunner & Suddarth, 2002). D.
Manifestasi Klinik Penyempitan lumen usus tadi mempengaruhi
kemampuan usus untuk mentranspor produk dari pencernaan usus atas
melalui lumen terkonstriksi dan akhirnya mengakibatkan nyeri abdomen
berupa kram. Karena peristaltic usus dirangsang oleh makana, maka nyeri
biasanya timbul setelah makan. Untuk menghindari nyeri ini, maka
sebagian pasien cenderung untuk membatasi masukan makanan,
mengurangi jumlah dan jenis makanan sehingga kebutuhan nutrisi normal
tidak terpenuhi. Akibatnya penurunan berat badan, malnutrisi, dan
anemia sekunder (Brunner & Suddarth, 2002). Selain itu, pembentukan
ulkus di lapisan membrane usus dan ditempat terjadinya inflamasi, akan
menghasilkan rabas pengiritasi konstan yang dialirkan ke kolon dari usus
yang tipis, bengkak, yang menyebabkan diare kronis. Kekurangan nutria
juga bisa terjadi karena gangguan pada absorbs. Akibanya adalah individu
menjadi kurus karena masukan makanan tidak adekuat dan cairan hilang
secara terusmenerus. Pada beberapa pasien, usus yang terinflamasi dapat
mengalami demam dan leukositosis (Brunner & Suddarth, 2002). E.
Pemeriksaan Penunjang Dengan penggunaan CT scan dan MRI, maka
dapat menunjukkan adanya penebalan dinding usus dan fistula saluran.
Hitung darah dapat dilakukan untuk mengkaji hematokrit dan kadar
hemoglobin yang biasanya menurun serta hitung sel darah putih yang
biasanya mengalami peningkatan. laju 2 sedimentasi biasanya akan
meningkat. Kadar albumin dan protein juga mengalami penurunan.
Penurunan nilai albumin dan protein ini dapat menjadi indicator pertanda
malnutrisi (Brunner & Suddarth, 2002). F. Penatalaksanaan Tindakan
medis ditujukan untuk mengurangi inflamasi, menekan respon imun dan
mengistirahatkan usus yang sakit. Untuk mengatasi masalah gangguan
nutrisi, maka dapat diberikan cairan oral, diet rendah residu, tinggi protein
tinggi kalori dan terapi suplemen vitamin pengganti besi.
Ketidakseimbangan cairan dan elektrolit yang dihubungkan dengan
dehidrasi akibat diare, diatasi dengan terapi intravena sesuai kebutuhan.
Sedangkan untuk terapi obatobatan, diberikan sedative dan antidiare/
antiperistaltik. Hal ini diberikan untuk mengistirahatkan usus yang
terinflamasi. Terapi ini dilanjutkan sampai frekuensi defekasi dan
konsistensi feses pasien mendekati normal. Selain itu diberikan pula
antibiotuk untuk mengatasi infksi sekunder dan pemberian obat-obatan
anti inflamasi (Brunner & Suddarth, 2002). ASUHAN KEPERAWATAN/ASKEP
A. Pengkajian Keperawatan Riwayat kesehatan diambil untuk
mengidentifikasi awitan, durasi dan karakteristik nyeri abdomen, adanya
diare atau dorongan fekal, mual, anoreksia atau penurunan berat badan
dan riwayat keluarga tentang penyakit usus inflamasi. Pengkajian pola
eliminasi usus mencakup karakter, frekuensi dan adanya darah, pus,
lemak, atau mucus. Alergi penting untuk dokumnetasi, khususnya
intoleransi usus atau lactose. Pasien menunjukkan gangguan pola tidur
bila diare atau nyeri terjadi padamalam hari. Pengkajian objektif
mencakup auskultasi abdomen terhadap bising usus dan karakteristiknya,
palpasi abdomen terhadap distensi, nyeri tekan, atau nyeri dan inspeksi
kulit terhadap bukti adanya saluran fistula atau gejala dehidrasi. 3 Feses
di inspeksi terhadap adanya darah dan mucus. Gejala paling utama
adalah nyeri intermitten yang terjadi pada diare tetapi tidak hilang setelah
defekasi. Nyeri pada daerah periumbilikal biasanya menunjukkan
keterlibatan ileum terminalis (Brunner & Suddarth, 2002). B. Diagnosa
Keperawatan Diagnosa keperawatan utama mencakup (Doengoes
Marylynn, 2002): 1. Perubahan nutrisi, kurang dari kebutuhan tubuh
berhubungan dengan pembatasna diet, mual dan malabsorbsi. 2. Nyeri
abdomen berhubungan dengan peningkatan peristaltic dan inflamasi 3.
Kurang volume cairan dan elektrolit berhubungan dengan anoreksia mual
dan diare 4. Perubahan suhu tubuh : hipertermia berhubungan dengan
inflamasi. 5. Gangguan pola tidur berhubungan dengan demam dan nyeri
C. Intervensi Keperawatan Diagnosa I : Perubahan nutrisi, kurang dari
kebutuhan tubuh berhubungan dengan pembatasan diet, mual dan
malabsorbsi. Intervensi (Wilkinson, 2007): 1. Kaji pola makan klien. 2. Buat
jadwal masukan tiap jam. Anjurkan cairan / makanan dan minum sedikit
demi sedikit. 3. Beri makanan yang bervariasi. 4. Anjurkan klien untuk
makan makanan lunak dengan porsi sedikit tapi sering. 5. Mengukur BB
tiap hari dengan timbangan yang sama. 6. Berikan Health Education
tentang pentingnya nutrisi. 7. Pantau status nutrisi melalui nilai
laboratorium khususnya albumin dan Hb 8. Kolaborasikan dengan ahli gizi
dalam menentukan kebutuhan protein untuk klien. 4 Diagnosa 2 : Nyeri
abdomen berhubungan dengan peningkatan peristaltic dan inflamasi
Intervensi (Wilkinson, 2007): : 1. Minta pasien untuk menilai nyeri/
ketidaknyamanan pada skala 0 – 10 ( 0 = tidak ada nyeri, 10 = nyeri yang
sangat) 2. Gunakan lembar alur nyeri untuk memantau pengurangan
nyeri dari analgesik dan kemungkinan efek sampingnya 3. Kaji dampak
agama, budaya, kepercayaan dan lingkungan terhadap nyeri dan respon
pasien 4. Lakukan pengkajian nyeri yang komprehensif meliputi lokasi,
karakteristis, waitan/ durasi, frekuensi, kualitas, intensitas atau keparahan
nyeri dan faktor presipitasinya 5. Observasi isyarat ketidaknyamanan
nonverbal, khususnya pada mereka yang tidak mampu
mengkomunikasikannya secara efektif. 6. Ajarkan penggunaan teknik
nonfarmakologi misalnya teknik relaksasi, imajinasi terbimbing, kompres
dan masase. 7. Kolaborasikan dengan pemberian obat analgesic Diagnosa
3 : Kurang volume cairan dan elektrolit berhubungan dengan anoreksia
mual dan diare Intervensi (Wilkinson, 2007): 1. Kaji pasien tentang adanya
tanda kekurangan volume cairan : kulit dan membrane mukosa kering,
penurunan turgor kulit, oliguria, kelelahan, penuruanan suhu, peningkatan
hematokrit, peningkatan berat jebis urin, dan hipotensi. 2. Anjurkan
paisen untuk meningkatkan intake cairan peroral 3. Catat intake dan
output cairan tubuh seperti cairan oral, muntah, drainase luka dan cairan
yang dikeluarkan melalui fistel 5 4. Timbanglah berat badan klien stiap
hari karena hal ini dapat menunjukkan adanya penambahan atau
kehilangan cairan yang terjadi secara cepat. 5. Berikan tindakan yang
dapat menurunkan frekuensi diare seprti pemberian obat antidiare,
pengurangan stress. Diagnosa 4 : Perubahan suhu tubuh : hipertermia
berhubungan dengan inflamasi. Intervensi (Wilkinson, 2007): 1. Pantau
terjadinya aktifitas kejang 2. Pantau adanya hidrasi pada klien dengan
mengkaji turgor kulit, kelembapan membran mukosa 3. Pantau tekanan
darah, nadi dan pernapasan 4. Anjurkan klien untuk meningkatkan asupan
cairan peroral 5. Anjurkan keluarga untuk membantu menurunkan demam
klien dengan memberikan kompres hangat 6. Kolaborasikan dalam
pemberian antibiotik Diagnosa 5 : Gangguan pola tidur berhubungan
dengan demam dan nyeri Intervensi (Wilkinson, 2007): 1. Hindari suara
keras dan penggunaan lampu saat tidur malam, berikan lingkungan yang
tenang, damai, dan minimalkan gangguan. 2. Bantu pasien untuk
mengidentifikasi faktor-faktor yang mungkin menyebabkan kurang tidur
seperti ketakutan, masalah yang tak terselesaikan dan konflik. 3. Ajarkan
pasien untuk menghindari makanan dan minuman pada jam tidur yang
dapat mengganggu tidur 4. Berikan tidur siang, jika diperlukan untuk
memenuhi kebutuhan tidur 5. Lakukan pijatan yang nyaman, pengaturan
posisi, dan sentuhan afektif. 6
Recommended

Laporan Kasus Enterokutan Fistel

Lp Fistula Enterokutan Anisa Nuri k

Fistel Uretrokutan Dan Penanganannya

Präaurikuläre, iatrogene, arteriovenöse Fistel

Orbitokutane Fistel nach Orbitarekonstruktion

Lapsus Fora Fistel Retroaurikula

Zur Technik der Eck’schen Fistel

Cholezysto-duodenale Fistel einmal anders


Haarnestcyste, perianale fistel, perianaal abces

Technische Vereinfachung der Eckschen Fistel

Auf einen Blick: Karotis-Sinus-cavernosus-Fistel

Thorako-Oesophageal-Fistel nach extrapleuraler Pneumolyse

Pulssynchroner Pendelnystagmus, Fistelsymptome ohne Fistel und


Lagefistelsymptom

Fistelsymptom bei Fistel am vertikalen Bogengang

Polyradikuläres Syndrom bei spinaler AV-Fistel

Gefäßkonglomerat mit arteriovenöser und venös-arterieller Fistel

Extralobäre Lungensequestration mit Fistel zum Oesophagus

Zur Frage des „Fistelsymptoms” ohne Fistel

A.V.-Fistel nach Implantation eines femoropoplitealen Bypasses

Doppelseitige nicht-traumatische Carotis-Sinus cavernosus-Fistel

View more >


 About Us
 Contact
 Term
 DMCA
 Cookie Policy
Copyright © 2017 VDOKUMENTS

 NCBI

S
kip to main content

S
kip to navigation
 Resources
 How To

A
bout NCBI Accesskeys
PMC
US National Library of Medicine

National Institutes of Health

Search database

Search term

Search

 Advanced
 Journal list

 Help

 Journal List

 Clin Colon Rectal Surg

 v.23(3); 2010 Sep

 PMC2967317

Clin Colon Rectal Surg. 2010 Sep; 23(3): 176–181.

doi: 10.1055/s-0030-1262985

PMCID: PMC2967317
PMID: 21886467

Enterocutaneous Fistulas
Guest Editor Scott R. Steele M.D.

Enterocutaneous Fistula Associated with Malignancy and


Prior Radiation Therapy
Luiz Felipe de Campos-Lobato, M.D.1 and Jon D. Vogel, M.D.1

Author information ► Copyright and License information ► Disclaimer

This article has been cited by other articles in PMC.

ABSTRACT
Enterocutaneous fistula (ECF) is defined as an anomalous communication between
the bowel and the skin.1 Surgical procedures involving the gastrointestinal tract
(GI), Crohn disease, neoplasia, and radiation are responsible for the majority of
ECF2. The initial management of ECF may be complex and includes resuscitation,
eradication of associated infections, control of ECF effluent, protection of the
surrounding skin, and nutritional support. Ultimately, most ECF will require
surgical repair.
In cases of ECF associated with cancer or radiation injury, the complexity of
management is only further increased. ECF in cancer patients will often delay or
prevent additional adjuvant therapy or palliative care, resulting in markedly poor
quality of life and survival.3Patients who have received radiotherapy to organs in
the abdomen or pelvis are at risk for radiation-induced damage to the intestinal
microvasculature, which may result in enteritis, strictures, abscess, or
fistula.4 Surgery on irradiated bowel is associated with poor healing, increased risk
of ECF, and decreased likelihood of spontaneous ECF closure. 5
Currently, multimodality therapy with chemotherapy, radiotherapy, and surgery is
the standard of care for a variety of intraabdominal malignancies. 6,7,8,9 It follows that
the incidence of cancer and radiation-associated ECF will be on the rise. However,
there are few recent data regarding the natural history and associated mortality of
ECF in cancer patients.3 Here we focus specifically on the management of ECF
associated with cancer and/or radiation-induced injury to the bowel.
Go to:

ETIOLOGY AND CLINICAL PRESENTATION


ECFs typically occur after operative procedures and, therefore, can often be
considered as iatrogenic.2 Missed injuries to the bowel that occurred during
surgery, disruption of repaired enterotomies, or anastomotic leak are the main
causes of surgery-related ECF.10Adherence to good surgical practice, with gentle
handling of the bowel, avoidance of tension or ischemia in the bowel anastomosis,
and the appropriate use of end or defunctioning ileostomies are generally thought
to be helpful in avoiding ECF after small bowel and colorectal surgery. 11,12 In
addition, preoperative anemia, malnutrition, and undrained abdominal infections
should, when possible, be dealt with prior to surgery with the aim of optimizing
the patient for an event-free operation and recovery. Use of preoperative
percutaneous drainage, antibiotics, and supplemental nutrition may be invaluable
with helping to minimize morbidity.
Yet even with the most diligent of care, ECF associated with malignancy may
result from a variety of settings as well as varying physiological states of the
patient. Cancer-associated ECF may unfortunately result from a perforated cancer,
where the patient may be in extremis and urgent operative intervention is required.
On the other hand, ECF may result following elective surgical resection of the
cancer complicated by a bowel injury or anastomotic leak, or even as a delayed
presentation from collateral damage to the bowel that occurs with the radiation
therapy or drug therapy that is used to treat the primary cancer.

Radiotherapy
Up to 75% of patients undergoing abdominal or pelvic radiation will suffer some
degree of radiation enteritis.13 In most cases this manifests as either bleeding or
stricture; however, a small percentage may develop fistulous complications. In this
subset of patients who develop a radiation-related ECF, it may take 6 months or
more for the fistula to become apparent. 10,14 Strategies to minimize radiation
enteritis include the surgical placement of a mesh prosthesis or omental flap to
isolate small bowel from the planned radiation field (e.g., the pelvis) and the use of
modern radiotherapy techniques such as three-dimensional preprocedural
evaluation and focused external beam therapy that are aimed at limiting collateral
radiation damage. In addition, appropriate use of neoadjuvant radiation therapy
may minimize small bowel exposure to radiation. Yet, despite these maneuvers, no
major reduction in ECF occurrence has been observed in recent studies. 11,12

Bevacizumab
Bevacizumab, a humanized monoclonal antibody to vascular endothelial growth
factor (Avastin; Genentech, San Francisco, CA) has become widely used for a
variety of neoplasias. This drug is generally well tolerated, but it has an adverse
affect on the healing process and is associated with spontaneous GI perforation
rates of 1 to 2%.15,16,17,18,19Some of these patients will require emergent surgical
treatment and some may be managed without surgery. In either scenario, ECF may
occur, and with it a particularly difficult problem in the setting of metastatic cancer
and often a nutritionally depleted and generally weakened patient. 20,21 Additionally,
the underlying negative effects of the agent on proper wound healing can have a
dramatic impact on ultimate outcome even with the most diligent of operative or
nonoperative care.

Cytoreductive Surgery and Intraperitoneal Hyperthermic Chemotherapy


Recently, the use of cytoreductive surgery and hyperthermic intraperitoneal
chemotherapy (C-HIPC) for the treatment of peritoneal carcinomatosis has gained
increased interest.22,23The aim of this multimodality therapy is to surgically remove
all gross tumor deposits from the peritoneal cavity and then use chemotherapy to
destroy any residual malignant cells. In most cases this involves prolonged
operative times, hemodynamic changes during the heated intraperitoneal
chemotherapy portion, and extensive surgical resections that may include large and
small bowel, liver, peritoneum, omentum, uterus, and spleen. On the positive side,
for colorectal cancer patients undergoing this procedure, 5-year overall survival
rates of 11 to 32% have been reported.23
Despite the potential benefits of C-HIPC, it is fraught with the potential for major
postoperative complications and death. Several authors have reported increased
rates of ECF after C-HIPC, though limited widespread use of this procedure make
rates variable.24,25,26 In some cases, these patients will present with multiple ECF or
ECF with an open abdomen, the so-called enteroatmospheric fistula, a truly
complex management problem for everyone who is involved in the care of the
patient.2
Go to:

DIAGNOSTIC STUDIES
Once the patient with ECF is stabilized, resuscitated, and the ECF is controlled, the
next steps are to determine if an abdominal or pelvic abscess is present, and then to
define the anatomy of the fistula. This is especially important in the setting of a
malignancy. Focus should be placed on determining the origin of the fistula and
whether this may represent tumor perforation or local versus remote complication
of prior therapy. Computed tomography (CT) scan or magnetic resonance imaging
(MRI), contrast studies of the bowel, fistulography, and endoscopy may be
required to achieve these objectives. CT and MRI are both useful to demonstrate
intestinal and extraintestinal pathology including residual cancer, abscess, adjacent
organ involvement (e.g., hydronephrosis or carcinomatosis), and sometimes the
anatomy of the fistula.27,28,29 Although CT is more generally available, less costly,
and often easier for surgeons to interpret than MRI, the ability of CT to define the
fistulous tract may not be as good as MRI.27,30 Whereas MRI has been
recommended for the preoperative assessment of complex perianal fistulas, 31,32the
accuracy of MRI in evaluating the proximal origin of ECF remains unclear, with
limited evidence to support its use in the setting of malignant ECF. 3,33,34,35,36
In cases of ECF in which an abdominal abscess is detected, treatment with
intravenous (IV) antibiotics and image-guided percutaneous drainage need to be
considered. When it is desirable to know the precise anatomy of the ECF,
fistulography may be required.37 With this study, injection of water-soluble contrast
into the external opening of the ECF is performed and then plain radiographs or
fluoroscopy are used to delineate the fistula pathway. The information obtained
from a fistulogram may complement the findings of CT and MRI and may be
helpful in planning surgical repair of the ECF; therefore, this test should be used
selectively—when the information obtained will be useful in the care of the
patient.
Go to:

TREATMENT

General Approach
In 1964, Chapman et al38 described the four cardinal principles in the initial care of
patients with ECF: correction of intravascular volume deficit, drainage of
abdominal abscess, control of fistula effluent, and skin protection. These
principles, described more than 40 years ago and covered in detail in other sections
of this issue, apply to all ECFs regardless of their etiology. In patients with ECFs
associated with cancer or radiation injury, additional diagnostic or treatment
approaches may be required. In this regard, collaboration with specialists in
radiation therapy and chemotherapy will often be necessary.

Surgical Approach
The first consideration in the surgical approach to ECF is the appropriate timing
for surgical intervention. One scenario to consider is the patient who underwent a
curative resection for colon cancer who then develops an ECF in the early
postoperative period. The cause of the ECF in this scenario is most often an
anastomotic leak or a missed enterotomy. The treatment options depend on the
timing of ECF presentation, the physiological condition of the patient, and the
complexity of the surgery that was performed.
When an ECF develops in the first 10 to 12 days after surgery, a return to the
operating room to address the problem surgically may be the best option for the
patient. In our practice, reoperation in these cases most often involves washout of
the peritoneal cavity, repair of the defect in the anastomosis, when possible, and
creation of a defunctioning loop ileostomy. In some cases, inflammation around the
leaking anastomosis or difficult access to the anastomosis (e.g., low pelvic)
precludes safe repair and diversion alone is performed. Most often, we use a
defunctioning loop ileostomy with preservation of the colon for possible future use
in a redo colorectal or coloanal anastomosis. In cases with extensive peritoneal
soiling, an ischemic anastomosis, or an unstable patient, it may be necessary to
take apart the anastomosis, close or drain the distal bowel, and create an end
ileostomy or colostomy. With either approach, the patient with an ECF is usually
able to quickly resume oral intake and is faced with an easily pouchable loop
ostomy rather than an ECF. Nevertheless, advocates of surgical treatment of early
postoperative ECF should also consider the potential of spontaneous healing of the
ECF.
After 3 months of diversion a water-soluble contrast enema is performed to
evaluate the anastomosis. If the anastomosis has healed then reversal of the
enterostomy can be performed. If a stricture is detected, an endoscopic evaluation
and possible stricture dilatation is indicated prior to takedown of the diverting
stoma to avoid the situation of a distal obstruction. If the contrast study reveals a
persistent leak then we typically have the patient wait another 3 months and
perform the contrast study again. At that point, if the leak persists then resection
and reconstruction of the anastomosis, with or without proximal diversion, is
required.
We will perform a simple reversal of the loop enterostomy as early as 2 to 3
months after it is made (so long as healing is confirmed); however, we will wait at
least 6 months, and preferably 9 to 12 months, before repeating a laparotomy. The
reasons for this are multifold, though include foremost the dense adhesions or
“obliterative peritonitis” that is often present as early as after postoperative day 10
to 12 and may persist for several months until the fibrous adhesion become softer,
less vascular, and more manageable by adhesolysis. 2,39,40
Clinical signs that may help the surgeon determine the appropriate timing for
reoperation include prolapse of the fistulating loops of bowel and mobility of the
peritoneal contents that can be appreciated by palpation and “rocking” of the
abdominal contents while the patient is laying supine. 41,42 Other considerations in
the timing of surgery for ECF are the nutritional and functional status of the
patient. Ideally, nutritional optimization, with weight gain and normalization of
serum albumin, correction of anemia, and physical rehabilitation are completed
before reoperation is performed.
In patients in whom an ECF develops early in the postoperative period who are not
good candidates for early reoperation (dense adhesions encountered at the first
operation or comorbid conditions that preclude safe reoperation), nonoperative
management of the ECF can be performed as described in other section of this
issue.

ENTEROCUTANEOUS FISTULA ASSOCIATED WITH A CANCER


In the patient with a small bowel or colon cancer that has evolved into an ECF, the
first step in surgical treatment is careful planning of the operation. In terms of
timing of the operation, the surgeon is usually not faced with the obstacles created
by a recent laparotomy. Rather, the patient with a perforated cancer and malignant
ECF most likely did not have a recent laparotomy, and depending on the patient's
physiological condition and control of the fistula, operative management can be
performed in a semielective or elective manner. In that case, cancer staging and
identification of collateral organ involvement (ureter, bladder, vagina, major
vessels, bone) are evaluated before going to the operating room. Consultation with
a medical oncologist and/or radiation oncologist is indicated. Depending on the
type of tumor, nonsurgical therapy may be the first or only line of
treatment.43,44,45,46,47
Once the decision is made to perform surgery, the following should be considered:
the need for ureteral stents; the availability of a urologist, vascular surgeon, or
plastic surgeon; the availability of blood products; and the need for preoperative
ostomy education and stoma marking. For malignant fistulas that involve the
terminal ileum or colon or rectum, preoperative colonoscopy is needed to exclude
synchronous colorectal cancers.
At surgery, the aim is curative resection of the cancer. This will involve en bloc
removal of the tumor along with the fistula tract and any structures that are
attached or invaded by the tumor or traversed by the fistula tract. Depending on the
location of the tumor and ECF, the patient is positioned on the operating table
either supine or in a modified lithotomy position. Our preference is to tuck the
patient's arms to maximize accessibility to the abdomen. A midline incision is
made several centimeters cephalad to the ECF so that the peritoneal cavity may be
entered in an area that may be less “hostile.” The surgeons' finger can then be
inserted into the peritoneal cavity, alongside the ECF, and the electrocautery is
used to incise the surrounding skin, muscle, and fascia with at least a 1-cm margin.
Once the ECF is encircled, the next step is to mobilize the mass of bowel and
mesentery that comprises the ECF. It is during this stage of the operation that the
surgeon will identify the ureters and determine if there are other organs or vessels
that are involved. The next step is to identify the loops of bowel that can be
preserved and the loops that must be resected with the ECF. Care must be taken in
patients with prior surgery to assess as much as possible the remaining length and
type (e.g., proximal/distal) of bowel remaining to avoid overaggressive resection
and resultant short bowel syndrome. The bowel and mesenteric resection is
performed in the usual manner and either bowel continuity is restored or an end
ostomy is created. When the decision is made to reconstruct the bowel, a
defunctioning proximal loop ileostomy or jejunostomy is made in nearly all cases
to ensure the best chance of an event and recurrent ECF-free recovery.
Closure of the abdomen is often quite difficult in the patients as there is typically a
large fascial defect that results, in part, from lateral retraction of the fascia, and, in
part, from the wide excision of the fascia that was performed during the initial
encirclement of the tumor and ECF. When primary closure of the rectus fascia is
not possible, our preference is to use a biological mesh prosthesis as a fascial
bridge, knowing full well that a subsequent hernia may develop and require
definitive repair once the cancer is under control and the patient has fully
recovered from the major stress of ECF repair.
In the patient with a malignant ECF that is not amenable to resection, either due to
inability to perform a curative resection or medical frailty of the patient, either a
palliative bypass or diverting ostomy creation may be considered. Palliative bypass
of a malignant ECF may be appropriate for the patient with a malignant ECF that
involves either the small bowel or colon. The operative technique for this usually
involves a sutured side-to-side anastomosis between proximal and distal segments
of uninvolved bowel. The aim of this operation is palliation with control of ECF
output, relief of obstruction, and avoidance of the need for an ostomy. The use of a
palliative ostomy may be best suited for malignant ECF associated with the distal
small bowel, colon, or rectum, as the ostomy should be distal enough to allow
adequate nutritional support via the enteral route and also to avoid a high-output
ostomy with its resultant fluid and electrolyte abnormalities.

POSTRADIOTHERAPY
Radiation enteritis is often a severe and irreversible condition. Irradiation results in
damage to the intestinal microvascular endothelium, 4 which may lead to fibrotic
strictures, full-thickness necrosis with free perforation or abscess, and fistula
formation.48 Surgery for radiation injury is typically performed for stricture but
may also be required for ECF. The type of fistula encountered in irradiated patients
is determined by the position of the original lesion requiring radiotherapy.
Therefore, the incidence of radiation-induced rectovaginal or colovesical fistulas
related to radiotherapy are much higher than radiation-induced ECF. 49,50
Patients suffering from radiation-induced ECF are likely to have other lesions
present at the same time. In one study, Cooke et al 51 found that, 6 of 28 patients
with rectovaginal fistula, had another associated fistula. In another review, Galland
et al52 found that these patients also have an increased risk for metachronous
radiation-induced pathology. For these reasons, it is important to exclude
synchronous fistulae before attempting a definitive surgical procedure and to
follow these patients after they undergo surgical treatment.
As for cancer-associated ECF, the surgical options for radiation-associated ECF are
resection, bypass, or diversion. Although resection may be the ideal therapy, it can
be difficult or even impossible in some cases due to “matting” together of adjacent
bowel loops, the ureters, nearby organs, or major vessels. In these situations,
bypass of the pathology (as described above) or formation of a diverting ostomy
may be the only surgical options.50 In patients who are unfit for definitive resection
or have disease that cannot be removed with curative intent, the diverting ostomy
may also be a satisfactory definitive measure. 12
When resection of the radiation-induced ECF can be performed, the preoperative
planning and surgical steps are in general similar to those that were described for
cancer-associated ECF. However, for radiation-associated ECF, the surgeon must
also consider that radiation injury may be present in nearby normal-appearing
small or large bowel. In patients who received irradiation to the pelvis, the terminal
ileum, cecum, ascending colon, and sigmoid colon may look and feel normal but
have in fact been compromised by radiation injury. The use of these bowel
segments for an anastomosis will increase the risk of leak and should therefore be
avoided.53
As with cancer-associated ECF, those that are related to radiation are also typically
associated with large abdominal defects that require major abdominal wall
reconstruction when the abdomen is closed. The complexity of abdominal wall
closure may be increased in patients with radiation ECF due to compromise of the
blood flow to the surrounding skin and soft tissues and major soft tissue flaps may
be required to improve the chances of a successful abdominal closure. In these
cases, the assistance of a plastic surgeon and wound management team will likely
improve the chances for success.54
Go to:

CONCLUSION
ECFs are a challenge no matter what the cause. The addition of cancer or radiation
injury only increases the challenge. The principles of ECF management in these
patients are the same as they are for benign ECF: resuscitation, control of ECF
output, eradication of infection, nutritional optimization, and the appropriate
timing for definitive repair. However, unique to cancer-associated ECF, the
involvement of both the radiation oncologist and medical oncologist is often
required before surgery is performed. For both cancer-related and radiation-related
ECF, the surgical options are resection, bypass, or diversion, with en bloc resection
the ideal option in most circumstances. Similar to the preoperative management,
the operative management of these patients often requires a multidisciplinary team
of specialists to ensure the best possible outcome.
Go to:

REFERENCES
1. Edmunds L H, Jr, Williams G M, Welch C E. External fistulas arising from the
gastro-intestinal tract. Ann Surg. 1960;152:445–471. [PMC free article] [PubMed]

2. Joyce M R, Dietz D W. Management of complex gastrointestinal fistula. Curr


Probl Surg. 2009;46(5):384–430. [PubMed]

3. Chamberlain R S, Kaufman H L, Danforth D N. Enterocutaneous fistula in cancer


patients: etiology, management, outcome, and impact on further treatment. Am
Surg. 1998;64(12):1204–1211. [PubMed]
4. Paris F, Fuks Z, Kang A, et al. Endothelial apoptosis as the primary lesion
initiating intestinal radiation damage in mice. Science. 2001;293(5528):293–
297. [PubMed]

5. Zimmerer T, Böcker U, Wenz F, Singer M V. Medical prevention and treatment of


acute and chronic radiation induced enteritis—is there any proven therapy? A
short review. Z Gastroenterol. 2008;46(5):441–448. [PubMed]

6. Sauer R, Becker H, Hohenberger W, et al. German Rectal Cancer Study Group


Preoperative versus postoperative chemoradiotherapy for rectal cancer. N Engl J
Med. 2004;351(17):1731–1740. [PubMed]

7. Morganti A G, Massaccesi M, La Torre G, et al. A systematic review of


resectability and survival after concurrent chemoradiation in primarily
unresectable pancreatic cancer. Ann Surg Oncol. 2010;17(1):194–205. [PubMed]

8. Rogers L, Siu S S, Luesley D, Bryant A, Dickinson H O. Adjuvant radiotherapy and


chemoradiation after surgery for cervical cancer. Cochrane Database Syst
Rev. 2009;(4):CD007583. [PubMed]

9. Stratton K L, Chang S S. Locally advanced prostate cancer: the role of surgical


management. BJU Int. 2009;104(4):449–454. [PubMed]

10. Lynch A C, Delaney C P, Senagore A J, Connor J T, Remzi F H, Fazio V W. Clinical


outcome and factors predictive of recurrence after enterocutaneous fistula
surgery. Ann Surg. 2004;240(5):825–831. [PMC free article] [PubMed]

11. Gordon P H. In: Gordon PH, Nivatvongs S, editor. Principles and Practice of
Surgery for the Colon, Rectum, and Anus. New York: Informa Health Care; 2007.
Principles and practice of surgery for the colon, rectum, and anus. pp. 104–134.

12. Corman M L. Colon and Rectal Surgery. Philadelphia: Lippincott Williams &
Wilkins; 2005.

13. Kozelsky T F, Meyers G E, Sloan J A, et al. North Central Cancer Treatment


Group Phase III double-blind study of glutamine versus placebo for the prevention
of acute diarrhea in patients receiving pelvic radiation therapy. J Clin
Oncol. 2003;21(9):1669–1674. [PubMed]

14. Meissner K. Late radiogenic small bowel damage: guidelines for the general
surgeon. Dig Surg. 1999;16(3):169–174. [PubMed]
15. Giantonio B J, Catalano P J, Meropol N J, et al. Eastern Cooperative Oncology
Group Study E3200 Bevacizumab in combination with oxaliplatin, fluorouracil, and
leucovorin (FOLFOX4) for previously treated metastatic colorectal cancer: results
from the Eastern Cooperative Oncology Group Study E3200. J Clin
Oncol. 2007;25(12):1539–1544.[PubMed]

16. Sandler A, Gray R, Perry M C, et al. Paclitaxel-carboplatin alone or with


bevacizumab for non-small-cell lung cancer. N Engl J Med. 2006;355(24):2542–
2550. [PubMed]

17. Wedam S B, Low J A, Yang S X, et al. Antiangiogenic and antitumor effects of


bevacizumab in patients with inflammatory and locally advanced breast cancer. J
Clin Oncol. 2006;24(5):769–777. [PubMed]

18. Kindler H L, Friberg G, Singh D A, et al. Phase II trial of bevacizumab plus


gemcitabine in patients with advanced pancreatic cancer. J Clin
Oncol. 2005;23(31):8033–8040. [PubMed]

19. Yang J C, Haworth L, Sherry R M, et al. A randomized trial of bevacizumab, an


anti-vascular endothelial growth factor antibody, for metastatic renal cancer. N
Engl J Med. 2003;349(5):427–434. [PMC free article] [PubMed]

20. Scappaticci F A, Fehrenbacher L, Cartwright T, et al. Surgical wound healing


complications in metastatic colorectal cancer patients treated with bevacizumab. J
Surg Oncol. 2005;91(3):173–180. [PubMed]

21. Heinzerling J H, Huerta S. Bowel perforation from bevacizumab for the


treatment of metastatic colon cancer: incidence, etiology, and management. Curr
Surg. 2006;63(5):334–337. [PubMed]

22. Sugarbaker P H. Cytoreductive surgery and peri-operative intraperitoneal


chemotherapy as a curative approach to pseudomyxoma peritonei syndrome. Eur
J Surg Oncol. 2001;27(3):239–243. [PubMed]

23. Esquivel J, Sticca R, Sugarbaker P, et al. Society of Surgical Oncology Annual


Meeting Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in
the management of peritoneal surface malignancies of colonic origin: a consensus
statement. Ann Surg Oncol. 2007;14(1):128–133. [PubMed]
24. Jaehne J. Cytoreductive procedures-strategies to reduce postoperative
morbidity and management of surgical complications with special emphasis on
anastomotic leaks. J Surg Oncol. 2009;100(4):302–305. [PubMed]

25. Yan T D, Morris D L. Cytoreductive surgery and perioperative intraperitoneal


chemotherapy for isolated colorectal peritoneal carcinomatosis: experimental
therapy or standard of care? Ann Surg. 2008;248(5):829–835. [PubMed]

26. Roviello F, Marrelli D, Neri A, et al. Treatment of peritoneal carcinomatosis by


cytoreductive surgery and intraperitoneal hyperthermic chemoperfusion (IHCP):
postoperative outcome and risk factors for morbidity. World J
Surg. 2006;30(11):2033–2040. discussion 2041–2042. [PubMed]

27. Schmidt S, Chevallier P, Bessoud B, et al. Diagnostic performance of MRI for


detection of intestinal fistulas in patients with complicated inflammatory bowel
conditions. Eur Radiol. 2007;17(11):2957–2963. [PubMed]

28. Salerno G, Daniels I R, Moran B J, Wotherspoon A, Brown G. Clarifying margins


in the multidisciplinary management of rectal cancer: the MERCURY
experience. Clin Radiol. 2006;61(11):916–923. [PubMed]

29. Brown G, Daniels I R. Preoperative staging of rectal cancer: the MERCURY


research project. Recent Results Cancer Res. 2005;165:58–74. [PubMed]

30. Outwater E, Schiebler M L. Pelvic fistulas: findings on MR images. AJR Am J


Roentgenol. 1993;160(2):327–330. [PubMed]

31. Bartram C, Buchanan G. Imaging anal fistula. Radiol Clin North


Am. 2003;41(2):443–457. [PubMed]

32. Semelka R C, Hricak H, Kim B, et al. Pelvic fistulas: appearances on MR


images. Abdom Imaging. 1997;22(1):91–95. [PubMed]

33. Pilleul F, Godefroy C, Yzebe-Beziat D, Dugougeat-Pilleul F, Lachaux A, Valette P


J. Magnetic resonance imaging in Crohn's disease. Gastroenterol Clin
Biol. 2005;29(8-9):803–808. [PubMed]

34. Albert J G, Martiny F, Krummenerl A, et al. Diagnosis of small bowel Crohn's


disease: a prospective comparison of capsule endoscopy with magnetic resonance
imaging and fluoroscopic enteroclysis. Gut. 2005;54(12):1721–1727. [PMC free
article] [PubMed]
35. Gourtsoyiannis N C, Grammatikakis J, Papamastorakis G, et al. Imaging of small
intestinal Crohn's disease: comparison between MR enteroclysis and conventional
enteroclysis. Eur Radiol. 2006;16(9):1915–1925. [PubMed]

36. Masselli G, Casciani E, Polettini E, Lanciotti S, Bertini L, Gualdi G. Assessment of


Crohn's disease in the small bowel: Prospective comparison of magnetic
resonance enteroclysis with conventional enteroclysis. Eur
Radiol. 2006;16(12):2817–2827.[PubMed]

37. Kwon S H, Oh J H, Kim H J, Park S J, Park H C. Interventional management of


gastrointestinal fistulas. Korean J Radiol. 2008;9(6):541–549. [PMC free
article] [PubMed]

38. Chapman R, Foran R, Dunphy J E. Management of intestinal fistulas. Am J


Surg. 1964;108:157–164. [PubMed]

39. Schecter W P, Hirshberg A, Chang D S, et al. Enteric fistulas: principles of


management. J Am Coll Surg. 2009;209(4):484–491. [PubMed]

40. Hill G L. Operative strategy in the treatment of enterocutaneous fistulas. World


J Surg. 1983;7(4):495–501. [PubMed]

41. Cameron J. Current Surgical Therapy. St. Louis, MO: Mosby; 2001.

42. Galie K L, Whitlow C B. Postoperative enterocutaneous fistula: when to


reoperate and how to succeed. Clin Colon Rectal Surg. 2006;19(4):237–246. [PMC
free article][PubMed]

43. Quah H M, Chou J F, Gonen M, et al. Identification of patients with high-risk


stage II colon cancer for adjuvant therapy. Dis Colon Rectum. 2008;51(5):503–
507. [PubMed]

44. Lavery I C, de Campos-Lobato L F. How to evaluate and identify stage II colon


cancer patients requiring referral to a medical oncologist: a surgeons
perspective. Oncology (Williston Park) 2010;24(1, Suppl 1):14–16. [PubMed]

45. Willett C G, Czito B G. Chemoradiotherapy in gastrointestinal


malignancies. Clin Oncol (R Coll Radiol) 2009;21(7):543–556. [PubMed]

46. Colombo N, Parma G, Zanagnolo V, Insinga A. Management of ovarian stromal


cell tumors. J Clin Oncol. 2007;25(20):2944–2951. [PubMed]
47. Chemoradiotherapy for Cervical Cancer Meta-Analysis Collaboration Reducing
uncertainties about the effects of chemoradiotherapy for cervical cancer: a
systematic review and meta-analysis of individual patient data from 18
randomized trials. J Clin Oncol. 2008;26(35):5802–5812. [PMC free
article] [PubMed]

48. Marks G, Mohiudden M. The surgical management of the radiation-injured


intestine. Surg Clin North Am. 1983;63(1):81–96. [PubMed]

49. Galland R B, Spencer J. Radiation-induced gastrointestinal fistulae. Ann R Coll


Surg Engl. 1986;68(1):5–7. [PMC free article] [PubMed]

50. Galland R B, Spencer J. Surgical management of radiation


enteritis. Surgery. 1986;99(2):133–139. [PubMed]

51. Cooke S A, de Moor N G. The surgical treatment of the radiation-damaged


rectum. Br J Surg. 1981;68(7):488–492. [PubMed]

52. Galland R B, Spencer J. Surgical aspects of radiation injury to the intestine. Br J


Surg. 1979;66(2):135–138. [PubMed]

53. Dworak J, Dietz D W. In: Fazio VW, Church JM, Delaney C, editor. Current
Therapy in Colon and Rectal Surgery. Philadelphia, PA: Elsevier Mosby; 2004.
Radiation enteritis and proctitis. pp. 491–498.

54. Landim F M, Tavares J M, Costa M L, Landim R M, Feitosa R G. Complex


abdominal wall reconstruction after radiation therapy: a full-thickness defect was
repaired with a rectus femoris myofasciocutaneous flap. Am J Obstet
Gynecol. 2009;200(1):116.e1–116.e3.[PubMed]

Articles from Clinics in Colon and Rectal Surgery are provided here courtesy of Thieme
Medical Publishers

Formats:
 Article
|

 PubReader
|

 ePub (beta)
|

 PDF (85K)
|

 Citation

Share

 Facebook

 Twitter

 Google+

Save items
Add to FavoritesView more options

Similar articles in PubMed


 An analysis of predictive factors for healing and mortality in patients with
enterocutaneous fistulas.[Aliment Pharmacol Ther. 2008]
 Historical perspectives in the care of patients with enterocutaneous fistula.[Clin Colon
Rectal Surg. 2010]
 Postoperative enterocutaneous fistula: when to reoperate and how to succeed.[Clin
Colon Rectal Surg. 2006]
 Enterocutaneous Fistula: Proven Strategies and Updates.[Clin Colon Rectal Surg.
2016]
 A systematic review of the benefit of total parenteral nutrition in the management of
enterocutaneous fistulas.[Minerva Chir. 2010]

See reviews...See all...

Cited by other articles in PMC


 Surgery for post-operative entero-cutaneous fistulas: is bowel resection plus primary
anastomosis without stoma a safe option to avoid early recurrence? Report on 20 cases by a
single center and systematic review of the literature[Il Giornale di Chirurgia. 2017]
 Enterocutaneous fistulas: a primer for radiologists with emphasis on CT and
MRI[Insights into Imaging. 2017]
 Malignant caeco-sigmoid fistula[BMJ Case Reports. 2014]

See all...
Links
 MedGen
 PubMed

Recent Activity
 Review Management of complex gastrointestinal fistula.[Curr Probl Surg. 2009]
 Clinical outcome and factors predictive of recurrence after enterocutaneous fistula
surgery.[Ann Surg. 2004]

 Phase III double-blind study of glutamine versus placebo for the prevention of acute
diarrhea in patients receiving pelvic radiation therapy.[J Clin Oncol. 2003]
 Clinical outcome and factors predictive of recurrence after enterocutaneous fistula
surgery.[Ann Surg. 2004]
 Review Late radiogenic small bowel damage: guidelines for the general surgeon.[Dig
Surg. 1999]

 Bevacizumab in combination with oxaliplatin, fluorouracil, and leucovorin (FOLFOX4)


for previously treated metastatic colorectal cancer: results from the Eastern Cooperative
Oncology Group Study E3200.[J Clin Oncol. 2007]
 Paclitaxel-carboplatin alone or with bevacizumab for non-small-cell lung cancer.[N
Engl J Med. 2006]
 Antiangiogenic and antitumor effects of bevacizumab in patients with inflammatory
and locally advanced breast cancer.[J Clin Oncol. 2006]
 Phase II trial of bevacizumab plus gemcitabine in patients with advanced pancreatic
cancer.[J Clin Oncol. 2005]

See more ...


 Cytoreductive surgery and peri-operative intraperitoneal chemotherapy as a curative
approach to pseudomyxoma peritonei syndrome.[Eur J Surg Oncol. 2001]
 Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in the
management of peritoneal surface malignancies of colonic origin: a consensus statement.
Society of Surgical Oncology.[Ann Surg Oncol. 2007]

 Review Cytoreductive procedures-strategies to reduce postoperative morbidity and


management of surgical complications with special emphasis on anastomotic leaks.[J Surg
Oncol. 2009]
 Cytoreductive surgery and perioperative intraperitoneal chemotherapy for isolated
colorectal peritoneal carcinomatosis: experimental therapy or standard of care?[Ann Surg.
2008]

See more ...


 Diagnostic performance of MRI for detection of intestinal fistulas in patients with
complicated inflammatory bowel conditions.[Eur Radiol. 2007]
 Review Clarifying margins in the multidisciplinary management of rectal cancer: the
MERCURY experience.[Clin Radiol. 2006]
 Review Preoperative staging of rectal cancer: the MERCURY research project.
[Recent Results Cancer Res. 2005]
 Pelvic fistulas: findings on MR images.[AJR Am J Roentgenol. 1993]
 Review Imaging anal fistula.[Radiol Clin North Am. 2003]
 Pelvic fistulas: appearances on MR images.[Abdom Imaging. 1997]
 Enterocutaneous fistula in cancer patients: etiology, management, outcome, and
impact on further treatment.[Am Surg. 1998]

See more ...


 Review Interventional management of gastrointestinal fistulas.[Korean J Radiol.
2008]

 MANAGEMENT OF INTESTINAL FISTULAS.[Am J Surg. 1964]

 Review Management of complex gastrointestinal fistula.[Curr Probl Surg. 2009]


 Review Enteric fistulas: principles of management.[J Am Coll Surg. 2009]
 Operative strategy in the treatment of enterocutaneous fistulas.[World J Surg. 1983]

 Postoperative enterocutaneous fistula: when to reoperate and how to succeed.[Clin


Colon Rectal Surg. 2006]

 Identification of patients with high-risk stage II colon cancer for adjuvant therapy.[Dis
Colon Rectum. 2008]
 How to evaluate risk and identify stage II patients requiring referral to a medical
oncologist: a surgeon's perspective.[Oncology (Williston Park). 2010]
 Review Chemoradiotherapy in gastrointestinal malignancies.[Clin Oncol (R Coll
Radiol). 2009]
 Review Management of ovarian stromal cell tumors.[J Clin Oncol. 2007]
 Review Reducing uncertainties about the effects of chemoradiotherapy for cervical
cancer: a systematic review and meta-analysis of individual patient data from 18 randomized
trials.[J Clin Oncol. 2008]

 Endothelial apoptosis as the primary lesion initiating intestinal radiation damage in


mice.[Science. 2001]
 The surgical management of the radiation-injured intestine.[Surg Clin North Am.
1983]
 Radiation-induced gastrointestinal fistulae.[Ann R Coll Surg Engl. 1986]
 Surgical management of radiation enteritis.[Surgery. 1986]

 The surgical treatment of the radiation-damaged rectum.[Br J Surg. 1981]


 Surgical aspects of radiation injury to the intestine.[Br J Surg. 1979]

 Surgical management of radiation enteritis.[Surgery. 1986]

 Complex abdominal wall reconstruction after radiation therapy: a full-thickness defect


was repaired with a rectus femoris myofasciocutaneous flap.[Am J Obstet Gynecol. 2009]
Support CenterSupport Center
E
xternal link. Please review our privacy policy.

NLM

NIH

DHHS

USA.gov

National Center for Biotechnology Information, U.S. National Library of Medicine8600 Rockville
Pike, Bethesda MD, 20894 USA

Policies and Guidelines | Contact