1. Review on enterocutaneous fistula

2. 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: ml / 24 hr
Low output: <200 ml / 24 hr
Current Management of Enterocutaneous Fistula
Journal of Gastrointestinal Surgery 2006;10:455–464

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

4. 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

5. Mortality
sepsis
Fluid and electrolyte disturbance
malnutrition

6. 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

7. 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:

8. Stabilization
Fluid and electrolyte correction
Sepsis control

9. 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

10. 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

11. 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

12. 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

13. 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)

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

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

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

17. 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

18. 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

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

20. 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

21. Definitive plan of management
Conservative
Surgery
Novel treatment

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

23. 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

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

25. 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%

26. 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)

27. Summary of management approach for ECF

28. END

29. 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

30. Gelfoam embolization
Percutaneous Gelfoam Embolization of Chronic Enterocutaneous Fistulas: Report of Three Cases
Disease of the Colon and Rectum 2006; 50: 251–256

31. Resection vs repair