ENTEROCUTANEOUS FISTULA, ANATOMY, CLASSIFICATION, PATHOPHYSIOLOGY, AND ITS MANAGEMENT

1. Management of
Enterocutaneous Fistula
Presenter:
Dr Anand Ujjwal Singh (JR1)
Moderators:
Dr. Laligen Awale
Dr. Rupesh Sah

2. Introduction
Classification
Pathophysiology
Phases of Management
Conclusion

3. INTRODUCTION
• Fistula : an abnormal communication between two epithelial surfaces.
• An enterocutaneous fistula (ECF) is an aberrant connection between the
intra-abdominal gastrointestinal (GI) tract and skin/wound.

4. • Enteric fistula may arise in a number of settings:
1. Diseased bowel extending to surrounding epithelialized tissue
2. Extraintestinal disease eroding into otherwise normal bowel
3. Surgical trauma to normal bowel
4. Anastomotic disruption following surgery

5. CLASSIFICATION
• On the basis of :
1. Etiology (Spontaneous vs Postoperative)
2. Anatomy of the structures involved
3. Amount and composition of drainage from the fistula

6. Etiological Variables
Postoperative complications (85%–90%) :
1. Unintentional enterotomy
2. Anastomotic breakdown a foreign body close to the suture line,
• tension on the suture line,
• complicated suture techniques,
• distal obstruction,
• hematoma,
• abscess formation at the anastomotic site,
• tumor.

7. 3. Emergent surgical procedures involving:
• unprepared bowel
• Under-resuscitation
• malnourishment or previously radiated tissue

8. Spontaneous fistula development (10%–15%):
• Crohn’s disease
• Malignancy and infectious processes, as in tuberculosis, diverticulitis
• Vascular insufficiency, radiation exposure and mesenteric ischemia.

9. Anatomical:
1. Internal:
-Two organs of same or different system
eg. Enteroenteral, enterovesical, enterocolic
2. External :
- Gut to body surface.
eg. Gastrocutaneous, duodenocutaneous, enterocutaneous.

10. Physiologic classification
According to output over a 24-hour period:
Low volume : <200 ml
Moderate volume : 200 - 500 ml
High volume : >500 ml
High volume fistulas are generally associated with high morbidity, high mortality
and less chance of spontaneous closure.

11. Pathophysiology
1. Loss of GI contents
Hypovolemia
Acid –Base and Electrolyte imbalances
2. Malnutrition
Decreased intake Vs High demand
Malabsorption
Altered C/P/F metabolism
Deficiency of vitamins , minerals

12. Management
The goal of treating entero-cutaneous fistulae is to
• restore bowel continuity,
• achieve oral nutrition, and
• close the fistulae.

13. SNAP
• Control of Sepsis and appropriate Skin care
• Nutrition
• Define underlying Anatomy
• Plan to deal with the fistula

14. PHASES
Recognition / stabilization
Investigation
Decision
Definitive management
Postsurgical

15. PHASE GOALS TIME COURSE
1. Recognition/
Stabilization
• Resuscitation with crystalloid, colloid or blood
• Control of sepsis with percutaneous or open
drainage and antibiotics
• Electrolyte repletion
• Provision of nutrition
• Control of fistula drainage
• Commencement of local skin care and
protection
24 – 48 hours
2.
Investigation • Fistulogram to define anatomy and
characteristics of fistula
• CT scan to define pathology
• Operative notes from prior surgery
7- 10 days

16. PHASE GOALS TIME COURSE
3. Decision • Evaluate the likelihood of spontaneous
closure
• Decide the duration of trial of nonoperative
management
10 days – 6 weeks
When closure, unlikely or
after 4-6 weeks
4. Definitive
management
• Plan operative approach
• Refunctionalization of entire bowel
• Resection of fistula with end- to –end
anastomosis
• Secure abdominal closure
• Gastrostomy and jejunostomy
Surgical intervention at 3-6
months after patient
stabilized

17. PHASE GOALS TIME COURSE
5. Post surgical • Usual postoperative period protocol
• Psychological and emotional support
• Ensure access to ICU for
management of potential
complications
• Multidisciplinary team
approach

18. Recognition / Stabilisation
1. Correction of dehydration, electrolyte imbalance
2. Correction of Anaemia, hypoproteinemia
3. Appropriate antibiotics and Drainage if local or systemic signs of
sepsis are evident.

19. 4. Output reduction
H2 receptor antagonists and PPIs
Sucralfate
Somatostatin analogs ( Inhibits stomach, pancreas, biliary tract and
small intestinal secretions are effective in resting the gut.)
NG tube (only in cases of distal obstruction)

20. Stabilisation (continued)
5. Control of Fistula Drainage and Skin Care
Strict output measurements
Dry dressings
Paints/ Ointments / Stoma glue for skin protection
VAC devices
Radiological guided Gelfoam embolization
Odour control

21. Techniques of skin care:
• Wound pouch dressings:
• One / two piece design
• Clip closure or Urostomy type
• May be attached to a bedside
bag or suction catheter

23. • Sump drainage:
• For fistulae draining with open abdominal wound
• Large bore drains or sumps
• High pressure suction

24. • VAC (Vacuum assisted closure):
Principle: decreases tissue bacterial level
 Removal of interstitial fluid
 Decreasing localized edema
 Increasing blood flow
Additionally, mechanical deformation of cells is thought to result in protein and matrix
molecule synthesis, which increases the rate of cell proliferation.
An introduction to the use of vacuum assisted closure, Steve Thomas, PhD, Director Surgical materials testing labaroty Bridgend, Wales, UK,
Published – May 2001

26. Nutrition
Gribovskaja-Rupp, I., & Melton, G.
(2016). Enterocutaneous Fistula: Proven Strategies
and Updates. Clinics in Colon and Rectal Surgery

27. Mode: Oral, Enteral or Parenteral
Oral route: colonic fistulas
Enteral route: esophageal and distal ileum fistulas.
TPN: high output proximal small bowel fistulas.

28. • Nutritional support needs to begin as soon as the patient is stabilized.
• Its advisable to provide atleast a part of the daily nutritional requirement through enteral
route.
• ORS should be given when oral intake is possible.
• TPN is also given in patients who do not tolerate enteral feeds or have long standing ileus
or before fistulous tract is well established.

29. Investigation
Fistulogram
Timing :7-10 days(maturation of the fistula track to introduce
contrast dye for investigation.)
Assists in the determination of:
• length and diameter of the tract,
• Site of bowel wall defect,
• Health of the adjacent bowel, and
• Presence of strictures, abscess cavities, distal obstruction, or anastomotic
dehiscence

30. Investigation
Other imaging modalities
• USG
• Computed tomography,
• Cystoscopy,
• Intravenous pyelogram .

35. Abdominal computed tomography scan of a patient with evidence of
actinomycosis on pathology. Notes: Enterocutaneous fistula (arrow) (A),
associated with large intra-abdominal abscess (arrow) (B)

36. Predictive factors for spontaneous
closure
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 less than
1cm
Tract <1cm, Defect >1cm

37. FACTORS THAT PREDICT FAILURE OF
SPONTANEOUS FISTULA CLOSURE:
1. Distal obstruction
2. Local infection
3. Foreign body
4. Open abdomen
5. Epithelialized tract
6. Fistula characteristics:
• Multiple fistula openings
• Defect > 1cm
• Short fistula tract
7. Abnormal bowel at origin of fistula (radiation, IBD)
8. Profound malnutrition
9. High-output fistula
10. Jejunal origin of fistula

38. Definitive surgery : Plans and principles
• 80-90 % will close within 6 weeks with conservative management.
• Surgery between 10 days and 6 weeks post-op will encounter worst
adhesions.
• Preferably wait up to 6 weeks before open exploration and repair of defect,
but in cases 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 hemodynamicaly stable.

39. • Definitive operative correction remains the final step in
the treatment of non-healing small intestinal fistula.
• In majority of cases, preferred operation is resection of
the involved segment with primary end to end
anastomosis.

40. • However if the 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.

41. MANAGEMENT OF ABDOMINAL WALL
FOLLOWING ELECTIVE CLOSURE
No Preoperative fascial defect:
• Primary closure with or without some fascial relaxation
Preoperative fascial defect:
Small defect:
• Primary fascial closure with or without some fascial relaxation
Large defect:
• Primary fascial closure using component separation technique
• Coverage with vascularized flap
• Use of prosthetic material

42. Major objective of management of abdominal wall:
• Prevent recurrent fistula formation
• Minimize postoperative infection
• Prevent late ventral hernia

43. Postsurgical phase
Two parts:
1. Early postsurgical recovery period
• Significant incidence of postoperative infections
• Incidence of recurrent fistulization
• Prolonged hospital stays
• Repeat admissions to ICU
• Repeat Intervention

44. • *Brenner et al reported that recurrence of enterocutaneous fistula in
the postoperative period was the strongest predictor of mortality,
invariably due to the development of overwhelming sepsis and organ
failure.

45. Factors predicting recurrence after elective
repair of enterocutaneous fistula:
Patient factors:
1. Open abdomen
2. Origin of fistula ( small bowel > large bowel)
3. Underlying inflammatory bowel disease
4. Frozen abdomen or residual intra-abdominal infection

46. Surgical factors:
1. Timing of surgery ( < 4 weeks, > 36 weeks)
2. Multiple inadvertent enterotomies at reoperation
3. Oversewing of enteric defect, rather than resection and
anastomosis
4. Use of stapled anastomosis, compared to hand-sewn anastomosis
5. Need to perform mesh closure of abdominal wall

47. 2. Rehabilitation and convalescence phase
• Physically deconditioned and emotionally fatigued
• Physical and occupational therapists
• Successful reintroduction to an active lifestyle

48. Conclusion:
• Enterocutaneous fistulas are abnormal communication between the gut and skin.
• Majority of the enterocutaneous fistula are due to iatrogenic causes ( 70- 85%).
• After initial stabilization of the patient by resuscitation, then subjected to various
investigations to dermine the location and anatomy of fistula and presence of
distal obstruction.

49. • Enteral nutrition is always preferable to parenteral nutrition provided the patient
tolerates enteral feeds.
• Local wound care is essential.
• Drainage of intra-abdominal collections, treatment of sepsis is of utmost importance.
• Enterocutaneous fistula with large abdominal defects may require VAC devices/ biologic
mesh/ SSG to help close the defect.