Enterocutaneous Fistulas

12/22/10
Enterocutaneous Fistula
An abnormal communication between two
epithelialized surfaces
Anatomic classification names according to organs
involved
High pressure to low
Aortoenteric, gastrocutaneous, colovesicle
Physiologic classification based on output
High-output > 500 cc/day
Difficulties in fluid management and skin care
Moderate-output 200-500 cc/day
Low-output < 200 cc/day
Usually colonic
Etiology of Fistula
Most often the result of anastomotic leak
Berry SM, Fischer JE. Enterocutaneous Fistulas.
Curr Probl Surg. 1994 Jun;31(6):469-566.
75-85% are iatrogenic
Typically after surgery for bowel obstruction, cancer,
or IBD
Extensive adhesiolysis is a major risk factor
Failure to recognize and adequately repair an
enterotomy leads to trouble

Mortality
Edmunds LH Jr, Williams GM, Welch CE. External
fistulas arising from the gastro-intestinal tract. Ann
Surg. 1960 Sep;152:445-71.
High-output fistulas 54%
Low-output fistulas 16%
Lvy E, Frileux P, Cugnenc PH, Honiger J, Ollivier JM,
Parc R. High-output external fistulae of the small
bowel: management with continuous enteral
nutrition. Br J Surg. 1989 Jul;76(7):676-9.
High-output fistulas 50%
Low-output fistulas 26%
FRIEND
Foreign body
Radiation
Inflammation, Infection
Epithelialization
Neoplasm
Distal obstruction

SNAP
Control of Sepsis and appropriate Skin care
Nutrition
Define underlying Anatomy
Plan to deal with the fistula
Management
Ensure eradication and control of sepsis
Any patient with intestinal fistula and evidence of
organ dysfunction (cardiac, respiratory, or renal
failure) will most likely have an undrained focus of
sepsis
Perc drainage is least invasive means of draining
collections
Catheter can be upsized
Studies can be done through tube to assess cavity
Antibiotics only if there is associated cellulitis

Management
Skin protection is essential
Effluent can be acidic or alkaline and cause skin to
be excoriated
Can lead to an unmanageable wound
Can also lead to bad body image

Nutrition
Normal energy expenditure 25 kcal/kg/day
Hypoalbuminemia is a significant risk factor for
mortality
Mortality rate of 42% with alb <2.5 vs 0% if >3.5
Nutritional support is mandatory if illness is
anticipated to be longer than 10 days
Good markers are albumin, prealbumin, transferrin,
and retinol binding protein
If the gut works, use it
> 75 cm of distal small bowel is required for
absorption

Anatomy
Must understand underlying pathology and
anatomy to manage fistula
CT
Barium vs water soluble contrast
Fistulogram

Plan
Majority (80-90%) will close within 6 weeks
with conservative management
Fazio VW, Coutsoftides T, Steiger E. Factors
influencing the outcome of treatment of small
bowel cutaneous fistula. World J Surg 1983;
7:481-8.
Surgery between 10 days and 6 weeks post-op will
encounter the worst adhesions
Preferably wait 6 months before surgery

Octreotide
Initially found to be beneficial in pancreatic fistulas
(Klempa et al. Prevention of postoperative pancreatic
complications following duodenopancreatectomy using
somatostatin, Chirurg 1979;50:427-31)
Inhibits endocrine and exocrine pancreatic secretion
and decreases splanchnic blood flow
Additional effects include inhibition of GI hormones, GI
secretions, gallbladder emptying, and gut motility
May decrease the output, but not shown to aid in
closure of fistulas
(Scott and Sancho)

Predictive factors for spontaneous
closure and/or mortality
Factor Favorable Unfavorable
Organ of origin Esophageal, Duodenal stump,
Pancreatic, Biliary, Jejunal,
Colonic
Gastric, Lateral duodenal,
Ligament of Treitz, Ileal
Etiology Postop (anast leak), Appendicitis,
Diverticulitis
Malignancy, IBD
Output Low (<200-500cc/day) High (>500cc/day)
Nutritional status Well nourished, Transferrin >200 Malnourished, Transferrin
<200
Sepsis Absent Present
State of bowel Intestinal continuity, absence of
obstruction
Diseased adjacent bowel,
Distal obstruction, Abscess,
Discontinuity, Irradiation
Fistula characteristics Tract >2 cm, Defect >1cm Tract <1cm, Defect >1cm
Miscellaneous Original operation at same
institution
Referred from outside
institution
Mesh use
Taner T, Cima RR, Larson DW, Dozois EJ, Pemberton JH,
Wolff BG. Surgical treatment of complex enterocutaneous
fistulas in IBD patients using human acellular dermal
matrix. Inflamm Bowel Dis. 2009 Aug;15(8):1208-12.
3 patients (27%) developed subcutaneous seroma
2 cases (18%) of superficial wound infection, all of which
resolved with conservative management
Mean length of hospital stay 13.5 (+/-7.2) days
There were no recurrences
1 patient with Crohn's disease developed a new ECF from a
separate bowel site, treated with the same surgical
approach
Additional References
Evenson AR, Fischer JE. Current Management
of Enterocutaneous Fistula. J Gastrointest
Surg 2006;10:455-464.
Joyce MR, Dietz DW. Management of complex
gastrointestinal fistula. Curr Probl Surg. 2009
May;46(5):384-430.