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ENTERO-

CUTANEOUS
FISTULA
DR.KASHINDRA SINGH
MEDICAL OFFICER,BMC.
Objectives

• Introduction

• Classification

• Etiology

• Clinical features and diagnosis

• Prevention

• Management
Introduction

• Fistula is defined as abnormal communication between two epithelized


surface.

• Entero-cutaneous fistula is an abnormal communication between the


skin with various parts of the gut, such as duodenum, jejunum etc.

• The word fistula means a “pipe” or “flute” in Latin.

• The ileum is the most common site of origin of Enterocutaneous fistula.


CLASSIFICATION
Gastrointestinal faecal fistula after an emergency
surgery for ileal perforation with severe peritonitis. Multiple faecal fistulous openings in the abdominal
Patient recovered wall. Patient has undergone laparotomy for acute
after long-term stay in the hospital peritonitis.
ETIOLOGY

Webster and Carey proposed five mechanisms of fistula formation :

1> Congenital : - Rare

- Failure of obliterate of Vitello-intestinal duct.

- Post natal slough of the stump.

2> Trauma : - Major penetrating trauma.

- Damage control laparotomy techniques


3> Infection : - intra abdominal Abscess and invasive intestinal infections
like amoebiasis, coccidiomycosis, tuberculosis etc.

- Intestinal perforation in ileum from tuberculosis or enteric fever

- Actinomyces infection post appendectomy.

4> Iatrogenic :

- Intra-abdominal abscess

- 75-85% are iatrogenic - after surgery for bowel obstruction,

cancer, or IBD
5> Inflammation, Irradiation or Tumour :

- Crohn’s disease may cause ECF – post op more common than


spontaneous.

- ECF after anastomosis/appendicectomy/simple exploration in Crohn’s


disease.

- Irradiation for pelvic malignancies etc may lead to a chronic non-


healing ECF.
Prevention of fistula

- Acute intra-operative perforations- early identification and closure.

- Serosal tears should be repaired immediately.

- Aggressive adhesiolysis should be avoided to prevent serosal tears.


Diagnosis of perforation and fistula

• Post operatively anastomotic leak

• Fever

• Abdominal pain

• Continuous drain containing intestinal content

• General condition not improving.


• Significant risk factor : systemically ill and sepsis

• Spontaneous closure rate depend upon : anatomy

etiology

nutritional status

output from fistula.

• Related complication: fluid and electrolyte imbalance

malnutrition

sepsis

local wound excoriation


Management
S-S-N-A-P

• Stabilization
• Sepsis control
• Skin care
• Nutrition
• Anatomy identification
• Plan to deal with the fistula
STABILIZATION
• In 24 to 48 hours.

• First step - resuscitation and stabilization of the patient.

• Initial efforts - intravenous fluid resuscitation

control of infection

protection of surrounding skin

measuring and replacing ongoing losses.

• Intra-abdominal/subcutaneous abscesses should be drained


RESUSCITATION
• Restoration of normal circulating blood volume
• correction of electrolyte and acid-base imbalance
• Initial management- RL and NS
• Strict input and output measurements
• CVP monitoring
• Urinary catheterization.
• Ongoing fluid losses should be fully replaced
• Associated with hypokalemia and metabolic acidosis- correction.
• Output of fistula should be monitored
• Urine output should be restored to greater than 0.5mL/kg/hr.
• If needed transfuse blood.
NUTRITION
• 73% of enteric fistulae closes spontaneously in adequately nourished patients, as
against 19% in malnourished patients.

• Nutritional support needs to begin as soon as the patient is stabilized.

• Nutrition can be parenteral or enteral route, based on the anatomy of the fistula.

• Its advisable to provide at least a part of the daily nutritional requirement through
enteral route.(adequate is 25%).

• Nutrition via the enteral route helps in maintaining the intestinal mucosal barrier,
more efficacious delivery of nutrients, stimulating hepatic protein synthesis.
• ORS should be given when oral intake is possible.

• In proximal fistulae, the enteral feeding tube may be entered beyond


the fistula to provide enteral nutrition.

• It is advisable to enter feeding tube beyond ligament of Treitz for a


gastric or duodenal fistula.

• TPN is also given in patients who do not tolerate enteral feeds or have
long standing ileus or before fistulous tract is well established.
Nutrition contd…
Control of sepsis and fistula Effluent
PHARMACOLOGICAL SUPPORT
• Somatostatin analogue Octreotide-100 – 250 mcg TDS reduces fistula output by 40 – 60% by the
end of 24 hrs.

• Should be discontinued if ineffective for 48 hrs (side effectshyperglycemia, elevated cholesterol


and reduced bowel motility).

• Octreotide and TPN seem to have a synergistic effect on reduction of effluent volume and
improvement in fistula closure rates.

• Proton-pump inhibitors and H2 receptor antagonists also help reduce fistula output especially in
proximal fistulas.

• Complications include URTI, headache, fatigue etc.


INVESTIGATION
• To locate Fistula

• X-ray- show any foreign body

• Oral dye / Charcoal – shows presence or absence, but not its location, cause or anatomy.

• USG - locating intra-abdominal abscesses, guided aspiration

• Fistulography- length & width of the fistula, anatomical location, the presence of any
distal obstructions

• CT Scan- oral and IV- highly recommended for duodenal & pancreatic fistula.

• Endoscopy -principal use is in internal fistulas.


DECISION
• 90% of small intestinal fistula which closed spontaneously within a month.
• 10 % fistulas closes spontaneously after 2 months and none after 3 months
• Factors possibly responsible for failure of spontaneous closure are:
Foreign Body
Radiation
Inflammation/ infection
Epithelialization [F-R-I-E-N-D-S]
Neoplasm
Distal intestinal obstruction
Steroids.
Definite therapy
DEFINITE THERAPY
• 80-90% will close within 6 weeks with conservative management.

• Surgery between 10 days and 6 weeks post-op will encounter the worst
adhesions.

• Preferably wait up to 6 weeks before open exploration and repair of defect,


but in case of fecal fistula, due to intense inflammation, it is prudent to wait
up to 10-12 weeks.

• The patient should by then, be nutritionally optimized, patient should not


be septic and patient should be vitally stable.
• Definitive operative correction remains the final step in the treatment of non-
healing small intestinal fistulas.

• In majority of the cases, preferred operation is resection of the involved


segment with primary end-to-end anastomosis.

• However if primary anastomosis is not possible, then both the proximal and

distal ends of intestine are exteriorized.


• In case the fistula is deemed inappropriate for resection, such as
when it develops after a deep pelvic procedure, staged approach
involving bypass should be considered.
BASIC PRINCIPLE OF SURGICAL
TREATMENT
• resection of the intestinal segment, fistula tract, and the adjacent part of the
involved structure

• absence of extensive infection or inflammation – primary anastomosis of the


divided intestinal segments and reestablish GI continuity

• presence of extensive infection - the divided intestinal segments are exteriorized.

• staged procedure is performed after the infection and inflammation subsides to re-
establish GI continuity and reconstruction of the affected structure after 10 weeks.
Conclusion

• Enterocutaneous fistulas are abnormal communication between the gut and

skin.

• Majority of the ECF are due to iatrogenic causes (70-85%). Others include

trauma, congenital causes. Spontaneous ECF may arise due to Crohn’s disease.

• Malnutrition, Electrolyte imbalances, acid-base imbalances and sepsis are the

major causes of mortality in ECF.


• After initial stabilization of the patient by resuscitation( fluid, electrolytes,
blood transfusions etc), the patient is subjected to various investigations to
determine the location& anatomy of fistula, presence of distal obstruction etc.

• Enteral nutrition is always preferable to parenteral nutrition provided the


patient tolerates enteral feeds.

• Local wound care by application of ostomy bag and pastes are essential.

• Drainage of intra-abdominal abscesses, treatment of sepsis is of utmost


importance.
• After proper optimization, patient undergoes definitive therapy which
includes resection of the fistulous segment of the gut.

• ECF with large abdominal defects may require VAC devices/ biologic
mesh SSG to help close the defect.
References …..

• Schwartz- principles of surgery ... 8th edition

• Baileys and love short textbook of surgery ..27th edition

• SRB’s manual of surgery..5th edition

• Google for images


THANK YOU 

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