Review on enterocutaneous fistula

Definition Enterocutaneous fistula Fistula output Abnormal pathological connection between skin and GI tract Fistula output High output > 500ml / 24 hr Non high output Moderate output: 200-500ml / 24 hr Low output: <200 ml / 24 hr Current Management of Enterocutaneous Fistula Journal of Gastrointestinal Surgery 2006;10:455–464

Causes Post abdominal surgery Malignancy Infection / inflammation Leading cause, 75-85% Malignancy Infection / inflammation IBD, diverticulitis, appendicitis, PPU, etc Radiation Abdominal trauma Congenital

Prognosis Mortality Spontaneous fistula closure Overall mortality 10-20% Mortality up to 30-35% for high output fistula Spontaneous fistula closure ~30%, range from 20-80% 80-90% closure within 6 weeks

Mortality sepsis Fluid and electrolyte disturbance malnutrition

Prognostic factors on fistula closure rate favorable unfavorable anatomical Esophageal, duodenal stump, pancreatobiliary, jejunal, colon Tract > 2cm Defect < 1cm Gastric, lateral duodenal, ileal Distal obstruction Complex fistula / associated abscess Epithelialization of tract etiological Post-operative Diverticulitis / appendicitis Malignancy IBD Foreign body Radiation general Malnutrition Sepsis Steroid / chemotherapy Co-morbidities Reference: Nutrition and Enterocutaneous Fistulas Journal of Clinical Gastroenterology 2000;31(3):195–204

Management approach for ECF SNAP S: stabilization, sepsis control, skin care N: nutrition support A: assessment of anatomy P: plan of definitive treatment / surgery Management of Complex Gastrointestinal Fistula Current Problems in Surgery 2009; 46: 384-430

Stabilization Fluid and electrolyte correction Sepsis control

Fluid and electrolyte Aggressive monitoring and replacement of fluid, electrolytes and acid-base Control of fistula output Modification of enteral intake NPO Restriction of hypo-osmolar fluid intake / intake of fluid rich in sodium / glucose Low residual diet / elemental diet Pharmacotherapy Anti-motility agents PPI Somatostatin / analogue

Somatostatin and its analogue Review on randomized controlled trial on effect of somatostatin / octreotide on fistula healing Nutrition and management of enterocutaneous fistula British Journal of Surgery 2006;93:1045–1055

Somatostatin and its analogue Time to closure Somatostatin may shorten time to closure Octreotide result inconsistent Fistula closure rate Most studies show no significant improvement in fistula healing rate with somatostatin / octreotide

Sepsis control Source of sepsis Assessment Drainage of collection Intra-abdominal collection Others: catheter related infection, skin infection, chest infection, UTI Assessment CT scan Drainage of collection Image guided percutaneous drainage Surgical drainage +/- proximal diversion

Skin care Various barrier device / skin protectants Suction drainage of fistula VAC system for open wound There were a few case series in which VAC was used in managing ECF with open wound successfully (Cro and colleagues, Gunn and colleague)

Skin care Current Management of Enterocutaneous Fistula Journal of Gastrointestinal Surgery 2006;10:455–464

Nutrition Nutrition and Enterocutaneous Fistulas Journal of Clinical Gastroenterology 2000;31(3):195–204

TPN Important in management of ECF Indicated when enteral feeding not feasible or inadequate

Enteral feeding vs bowel rest No randomized trials investigating outcomes in patients with early enteral feeding vs complete bowel rest have been performed Experience from studies with aggressive approach to early enteral nutrition show similar outcome in terms of mortality and fistula closure rate compared to other studies with more parenteral nutrition

Enteral feeding Preferred if feasible after initial stabilization Improve mucosal integrity Avoid complication of TPN Access Oral Feeding tube / stoma distal to fistula Fistuloclysis: tube feeding via fistula to distal limb of GI tract

Assessment of anatomy Site of origin of fistula Anatomy of fistula tract Complexity Length of tract Defect size Status of distant bowel Integrity obstruction

Assessment of anatomy CT scan Fistulogram Other GI contrast study MRI Intra-abdominal collection Underlying causes Fistulogram Anatomy of fistula tract and GI tract Other GI contrast study MRI Endoscopy

Definitive plan of management Conservative Surgery Novel treatment

Spontaneous closure unlikely.. FRIEND Foreign body Radiation injury Inflammatory bowel disease Epithelialization of fistula tract Neoplasm Distal obstruction

Surgical intervention Indications Conservative management fails Sepsis cannot be controlled Timing of surgery Preferably 3-6 months after presentation / previous operation unless life-threatening sepsis Patient well optimized and disease well assessed

Surgical intervention Surgical approach Incision and access Adequate mobilization / assessment of bowel Resection vs repair Diversion: stoma / bypass Abdominal wall closure

Surgical intervention Resection of diseased bowel with primary anastomosis more preferable than repair of defect if possible Lower risk of recurrence as demonstrated in a retrospective study from Cleveland (Annals of Surgery, Volume 240, Number 5, November 2004) General rate of recurrence after surgery ranged from 10-35%

Novel treatment Fibrin glue Gelfoam embolization A non randomized study from Mexico study on the use of fibrin glue on patients with low output fistula and showed shorter healing time compared to control group (World Journal of Gastroenterology, 2010 June 14; 16 (22): 2793 – 2800) Gelfoam embolization Fluoroscopic guided placement of catheter at the enteric opening of the fistula and gelfoam was injected to occlude the fistula at its enteric opening A case series from Australia (Lisle and colleagues) reported successful use of gelfoam embolization in treating 3 patients with low output fistula (Disease of the Colon and Rectum 2006; 50: 251–256)

Summary of management approach for ECF

END

Fistuloclysis A case series was reported in UK (Teubner and colleagues), in which fistuloclysis was attempted in 12 patients with small bowel fistulas, 11 out of the 12 patients were able to wean 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 embolization Percutaneous Gelfoam Embolization of Chronic Enterocutaneous Fistulas: Report of Three Cases Disease of the Colon and Rectum 2006; 50: 251–256

Resection vs repair