Review on Review on enterocutaneous enterocutaneous

fistulafistula

DefinitionDefinition►Enterocutaneous fistulaEnterocutaneous fistula

Abnormal pathological connection Abnormal pathological connection between skin and GI tractbetween skin and GI tract

►Fistula outputFistula output High outputHigh output

►> 500ml / 24 hr> 500ml / 24 hr

Non high outputNon high output►Moderate output: 200-500ml / 24 hrModerate output: 200-500ml / 24 hr►Low output: <200 ml / 24 hrLow output: <200 ml / 24 hr

Current Management of Enterocutaneous Fistula

Journal of Gastrointestinal Surgery 2006;10:455–464

CausesCauses

►Post abdominal surgeryPost abdominal surgery Leading cause, 75-85%Leading cause, 75-85%

►MalignancyMalignancy► Infection / inflammationInfection / inflammation

IBD, diverticulitis, appendicitis, PPU, etcIBD, diverticulitis, appendicitis, PPU, etc

►RadiationRadiation►Abdominal traumaAbdominal trauma►CongenitalCongenital

PrognosisPrognosis

►MortalityMortality Overall mortality 10-20%Overall mortality 10-20% Mortality up to 30-35% for high output Mortality up to 30-35% for high output

fistulafistula

►Spontaneous fistula closureSpontaneous fistula closure ~30%, range from 20-80% ~30%, range from 20-80% 80-90% closure within 6 weeks80-90% closure within 6 weeks

MortalityMortality

sepsis

malnutrition Fluid and electrolyte disturbance

Prognostic factors on fistula Prognostic factors on fistula closure rateclosure rate

favorablefavorable unfavorableunfavorable

anatomicalanatomicalEsophageal, duodenal Esophageal, duodenal stump, pancreatobiliary, stump, pancreatobiliary, jejunal, colonjejunal, colonTract > 2cmTract > 2cmDefect < 1cmDefect < 1cm

Gastric, lateral Gastric, lateral duodenal, ilealduodenal, ilealDistal obstructionDistal obstructionComplex fistula / Complex fistula / associated abscessassociated abscessEpithelialization of tractEpithelialization of tract

etiologicaletiologicalPost-operativePost-operativeDiverticulitis / Diverticulitis / appendicitisappendicitis

MalignancyMalignancyIBDIBDForeign bodyForeign bodyRadiationRadiation

generalgeneralMalnutritionMalnutritionSepsisSepsisSteroid / chemotherapySteroid / chemotherapyCo-morbiditiesCo-morbidities

Reference: Nutrition and Enterocutaneous Fistulas

Journal of Clinical Gastroenterology 2000;31(3):195–204

Management approach for Management approach for ECFECF

►SNAPSNAP S: stabilization, sepsis control, skin careS: stabilization, sepsis control, skin care N: nutrition supportN: nutrition support A: assessment of anatomyA: assessment of anatomy P: plan of definitive treatment / surgeryP: plan of definitive treatment / surgery

Management of Complex Gastrointestinal Fistula

Current Problems in Surgery 2009; 46: 384-430

StabilizationStabilization

►Fluid and electrolyte correctionFluid and electrolyte correction►Sepsis controlSepsis control

Fluid and electrolyteFluid and electrolyte

► Aggressive monitoring and replacement of Aggressive monitoring and replacement of fluid, electrolytes and acid-basefluid, electrolytes and acid-base

► Control of fistula outputControl of fistula output Modification of enteral intakeModification of enteral intake

► NPONPO► Restriction of hypo-osmolar fluid intake / intake of fluid Restriction of hypo-osmolar fluid intake / intake of fluid

rich in sodium / glucoserich in sodium / glucose► Low residual diet / elemental dietLow residual diet / elemental diet

PharmacotherapyPharmacotherapy► Anti-motility agentsAnti-motility agents► PPIPPI► Somatostatin / analogueSomatostatin / analogue

Somatostatin and its Somatostatin and its analogueanalogue

► Review on randomized controlled trial on Review on randomized controlled trial on effect of somatostatin / octreotide on fistula effect of somatostatin / octreotide on fistula healinghealing

Nutrition and management of enterocutaneous fistula

British Journal of Surgery 2006;93:1045–1055

Somatostatin and its Somatostatin and its analogueanalogue

►Time to closureTime to closure Somatostatin may shorten time to closureSomatostatin may shorten time to closure Octreotide result inconsistentOctreotide result inconsistent

►Fistula closure rateFistula closure rate Most studies show no significant Most studies show no significant

improvement in fistula healing rate with improvement in fistula healing rate with somatostatin / octreotidesomatostatin / octreotide

Sepsis controlSepsis control

►Source of sepsisSource of sepsis Intra-abdominal collectionIntra-abdominal collection Others: catheter related infection, skin Others: catheter related infection, skin

infection, chest infection, UTIinfection, chest infection, UTI►AssessmentAssessment

CT scanCT scan►Drainage of collectionDrainage of collection

Image guided percutaneous drainageImage guided percutaneous drainage Surgical drainage +/- proximal diversionSurgical drainage +/- proximal diversion

Skin careSkin care

►Various barrier device / skin Various barrier device / skin protectantsprotectants

►Suction drainage of fistulaSuction drainage of fistula►VAC system for open woundVAC system for open wound

There were a few case series in which VAC There were a few case series in which VAC was used in managing ECF with open was used in managing ECF with open wound successfully (Cro and colleagues, wound successfully (Cro and colleagues, Gunn and colleague)Gunn and colleague)

Skin careSkin care

Current Management of Enterocutaneous Fistula

Journal of Gastrointestinal Surgery 2006;10:455–464

NutritionNutrition

Nutrition and Enterocutaneous Fistulas

Journal of Clinical Gastroenterology 2000;31(3):195–204

TPNTPN

► Important in management of ECFImportant in management of ECF► Indicated when enteral feeding not Indicated when enteral feeding not

feasible or inadequatefeasible or inadequate

Enteral feeding vs bowel restEnteral feeding vs bowel rest

►No randomized trials investigating No randomized trials investigating outcomes in patients with early enteral outcomes in patients with early enteral feeding vs complete bowel rest have feeding vs complete bowel rest have been performedbeen performed

►Experience from studies with aggressive Experience from studies with aggressive approach to early enteral nutrition show approach to early enteral nutrition show similar outcome in terms of mortality and similar outcome in terms of mortality and fistula closure rate compared to other fistula closure rate compared to other studies with more parenteral nutritionstudies with more parenteral nutrition

Enteral feedingEnteral feeding

►Preferred if feasible after initial Preferred if feasible after initial stabilizationstabilization Improve mucosal integrityImprove mucosal integrity Avoid complication of TPNAvoid complication of TPN

►AccessAccess OralOral Feeding tube / stoma distal to fistulaFeeding tube / stoma distal to fistula Fistuloclysis: tube feeding via fistula to Fistuloclysis: tube feeding via fistula to

distal limb of GI tractdistal limb of GI tract

Assessment of anatomyAssessment of anatomy

►Site of origin of fistulaSite of origin of fistula►Anatomy of fistula tractAnatomy of fistula tract

ComplexityComplexity Length of tractLength of tract Defect sizeDefect size

►Status of distant bowelStatus of distant bowel IntegrityIntegrity obstructionobstruction

Assessment of anatomyAssessment of anatomy

►CT scanCT scan Intra-abdominal collectionIntra-abdominal collection Underlying causesUnderlying causes

►FistulogramFistulogram Anatomy of fistula tract and GI tractAnatomy of fistula tract and GI tract

►Other GI contrast studyOther GI contrast study►MRIMRI►EndoscopyEndoscopy

Definitive plan of Definitive plan of managementmanagement

►ConservativeConservative►SurgerySurgery►Novel treatmentNovel treatment

Spontaneous closure Spontaneous closure unlikely..unlikely..

►FRIENDFRIEND Foreign bodyForeign body Radiation injuryRadiation injury Inflammatory bowel diseaseInflammatory bowel disease Epithelialization of fistula tractEpithelialization of fistula tract NeoplasmNeoplasm Distal obstructionDistal obstruction

Surgical interventionSurgical intervention

► IndicationsIndications Conservative management failsConservative management fails Sepsis cannot be controlledSepsis cannot be controlled

►Timing of surgeryTiming of surgery Preferably 3-6 months after presentation / Preferably 3-6 months after presentation /

previous operation unless life-threatening previous operation unless life-threatening sepsissepsis

Patient well optimized and disease well Patient well optimized and disease well assessedassessed

Surgical interventionSurgical intervention

►Surgical approachSurgical approach Incision and accessIncision and access Adequate mobilization / assessment of Adequate mobilization / assessment of

bowel bowel Resection vs repairResection vs repair Diversion: stoma / bypassDiversion: stoma / bypass Abdominal wall closureAbdominal wall closure

Surgical interventionSurgical intervention

►Resection of diseased bowel with Resection of diseased bowel with primary anastomosis more preferable primary anastomosis more preferable than repair of defect if possiblethan repair of defect if possible Lower risk of recurrence as demonstrated Lower risk of recurrence as demonstrated

in a retrospective study from Cleveland in a retrospective study from Cleveland (Annals of Surgery, Volume 240, Number (Annals of Surgery, Volume 240, Number 5, November 2004)5, November 2004)

General rate of recurrence after surgery ranged from 10-35%

Novel treatmentNovel treatment

► Fibrin glueFibrin glue A non randomized study from Mexico study on the use of A non randomized study from Mexico study on the use of

fibrin glue on patients with low output fistula and showed fibrin glue on patients with low output fistula and showed shorter healing time compared to control group (World shorter healing time compared to control group (World Journal of Gastroenterology, 2010 June 14; 16 (22): 2793 Journal of Gastroenterology, 2010 June 14; 16 (22): 2793 –– 2800)2800)

► Gelfoam embolizationGelfoam embolization Fluoroscopic guided placement of catheter at the enteric Fluoroscopic guided placement of catheter at the enteric

opening of the fistula and gelfoam was injected to occlude opening of the fistula and gelfoam was injected to occlude the fistula at its enteric openingthe fistula at its enteric opening

A case series from Australia (Lisle and colleagues) reported A case series from Australia (Lisle and colleagues) reported successful use of gelfoam embolization in treating 3 successful use of gelfoam embolization in treating 3 patients with low output fistula (patients with low output fistula (Disease of the Colon and Disease of the Colon and Rectum 2006; 50: 251Rectum 2006; 50: 251––256)256)

Summary of management Summary of management approach for ECFapproach for ECF

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FistuloclysisFistuloclysis

►A case series was reported in UK A case series was reported in UK (Teubner and colleagues), in which (Teubner and colleagues), in which fistuloclysis was attempted in 12 fistuloclysis was attempted in 12 patients with small bowel fistulas, 11 patients with small bowel fistulas, 11 out of the 12 patients were able to out of the 12 patients were able to wean off TPNwean off TPN

Fistuloclysis can successfully replace parenteral feeding in the nutritional support of patients with enterocutaneous fistula

British Journal of Surgery 2004;91:625–631

Gelfoam embolizationGelfoam embolization

Percutaneous Gelfoam Percutaneous Gelfoam Embolization of Chronic Embolization of Chronic Enterocutaneous Fistulas: Report Enterocutaneous Fistulas: Report of Three Casesof Three Cases

Disease of the Colon and Rectum Disease of the Colon and Rectum 2006; 50: 2512006; 50: 251––256256

Resection vs repairResection vs repair