Enterocutaneous fistula

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1. ENTEROCUTANEOUS FISTULA Dr. Simba Fidel

2. Outline Introduction Classification Etiology & Risk Factors Clinical Features Diagnosis Management

3. Introduction A fistula is an abnormal connection between two epithelialized hollow spaces or organs. Enterocutaneous fistula is an abnormal communication between the skin with various parts of the gut. Fistula means “pipe” or “flute” in latin . The ileum is the most common site of origin of ECF.

4. Classification ECF are classified according to source, output volume, and etiology. By source : i.e gastro-, duodeno -, jejuno -, ileo -, colo -, recto- By output volume ; Low output; <200ml/day Moderate output; 200ml-500ml/day High output; >500ml/day By Etiology

5. Etiology Webster and Carey proposed 5 general mechanisms for intestinal fistula formation; Congenital : complete failure of the vitellointestinal duct to obliterate, which results in a ECF to the umbilicus Trauma : enteroatmospheric fistulas after damage control laparotomy Infection : Actinomyces is a common cause of ECF after appendicectomy . Perforation or injury with abscess : Iatrogenic Infammation , Irradiation or tumor

6. Etiology (ECF) are commonly iatrogenic (75-85%) and are the most common type of small bowel fistula

7. Clinical Features Iatrogenic enterocutaneous fistulas usually become clinically evident between the 5 th and 10 th postop days. Fever, leukocytosis , prolonged ileus, abdominal tenderness, and wound infection are the initial signs . An enteric fistula can be distinguished from a wound infection by the presence of bile in the wound.

8. Diagnosis The diagnosis of an enterocutaneous fistula is clinical. Abd CT: the most useful initial test, with enteral contrast GI series; eg Enteroclysis , or barium follow-through Fistulogram

9. Management The treatment of enterocutaneous fistulas should proceed through an orderly sequence of steps; Stabilization Sepsis control Skin care Nutrition Anatomy identification Decision and definitive management

10. Management Stabilization; In the first 24hr-48hr Aggressive correction of hypovolemia and electrolyte loss should occur early, Ongoing fluid losses from moderate-output upper gastrointestinal fistulas should be replaced with saline and potassium supplementation with serial measurements of serum electrolytes Duodenal or pancreatic fistulas may require bicarbonate replacement to prevent metabolic acidosis.

11. Management Sepsis Control; Patients who have diffuse peritonitis or evidence of free gastrointestinal perforation on imaging studies require urgent surgical exploration. Diversion of the fecal stream by ostomy is often required and is the preferred approach. Hemodynamically stable patients without diffuse peritonitis should undergo abd (CT ) to identify any intra-abdominal source of sepsis; i.e abscess Antibiotic management in nonseptic patients with an enterocutaneous fistula is controversial

12. Management Skin care; Wound bags; i.e ostomy bags NPWT

13. Management Pharmacological treatment; Anticarthatics ; eg Loperamide and diphenoxylate -atropine ( Lomotil ) for diarrhea and high output fistulas Somatostatin analogs ; eg Octreotide (SC/IM 50mcg-100mcg q 8-12hrly) Antisecretories ; eg PPIs and Histamine-2 receptor antagonists Cholestyramine  — For the uncommon bilioenteric fistula ( eg , biliary-colonic), cholestyramine can be tried.

14. Management Nutrition; 73% of enteric fistulae closes spontaneously in adequately nourished patients, Nutritional support needs to begin as soon as the patient is stabilized Parenteral vs enteral depending on the anatomy of the fistulanutrition via enteral route helps in maintaining the intestinal mucosal barrier, It is advisable to provide at least part of daily nutritional requirement via enteral. (25%) In proximal fistula, the enteral feeding tube may be entered beyond the fistula to provide enteral nutrition

15. Nutrition TPN is given in patients who do not tolerate enteral feeds or have longstanding ileus or before fistulous tract is well established. For Low output  caloric req of 30-35kcal/kg/day, & 1-1.5g/kg/d High output  45-50kcal/kg/day, & 1.5-2.5g/kg/d of protein intake Vitamins, trace elements, zinc and upto 10times the daily requirements of VitC should be provided Mortality rate of 42% with albumin <2.5mg/dl, vs 0% if > 3.5mg/dl N.B: for high output NGT, put NPO, and start TPN.

16. Definitive therapy Non-operative fistula closure; Covered enteric stents Endoscopic clipping Fistula plugs Fibrin sealant

17. Operative management 80-90% will close within 5-6weeks with conservative management Surgery done btn 10days and 6wks post-op will encounter the worst adhesions Most surgeons would pursue 2 to 3 months of conservative therapy before considering surgical intervention. Specialized centers often delay the definitive surgery for 6 to 12 months The patient should by then be nutritionally optimized, should not be septic

18. Basic Principles of S urgical 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 In presence of extensive infection  the divided intestinal segments are exteriorized and Staged procedure is performed after the infection and inflammation subsides.

19. Outcome Over 60 % of intestinal fistulas close spontaneously. Operative repair was associated with a 30-day mortality of approximately 4% and a 1-year mortality of 15%. Morbidity was over 80%. First attempt at surgical repair was successful in 70% of cases

20. Prevention of Fistula Acute intra-operative perforations; early identification and closure Serosal tears should be repaired Aggressive adhesiolysis should be avoided to prevent serosal tears

21. Take Home ECF are abdnormal are abnormal communication btn the gut and skin Majority of ECF are due to iatrogenic causes (70-80%). Others include trauma, congenital and the FRIEND mnemonic Diagnosis is clinical. Imagings are adjunct for anatomy identification and ruling out intra abdominal abscesses Drainage of intra abdominal abscess and treatment of sepsis is of utmost importance. Most ECF will close spontaneously within 5-6wks, if not a definitive treatment can be decided on.

22. References Schwarts Principles of Surgery Uptodate.com COSECSA MCS notes 2021

23. Murakoze ! Asanteni !