1. Enterocutaneous Fistulas 12/22/10

2. Enterocutaneous Fistula An abnormal communication between two epithelialized surfaces Anatomic classification names according to organs involved – High pressure to low – Aortoenteric, gastrocutaneous, colovesicle Physiologic classification based on output – High-output > 500 cc/day Difficulties in fluid management and skin care – Moderate-output 200-500 cc/day – Low-output < 200 cc/day Usually colonic

3. Etiology of Fistula Most often the result of anastomotic leak Berry SM, Fischer JE. Enterocutaneous Fistulas. Curr Probl Surg. 1994 Jun;31(6):469-566. – 75-85% are iatrogenic – Typically after surgery for bowel obstruction, cancer, or IBD Extensive adhesiolysis is a major risk factor – Failure to recognize and adequately repair an enterotomy leads to trouble

4. Mortality Edmunds LH Jr, Williams GM, Welch CE. External fistulas arising from the gastro-intestinal tract. Ann Surg. 1960 Sep;152:445-71. – High-output fistulas 54% – Low-output fistulas 16% Lévy E, Frileux P, Cugnenc PH, Honiger J, Ollivier JM, Parc R. High-output external fistulae of the small bowel: management with continuous enteral nutrition. Br J Surg. 1989 Jul;76(7):676-9. – High-output fistulas 50% – Low-output fistulas 26%

5. FRIEND Foreign body Radiation Inflammation, Infection Epithelialization Neoplasm Distal obstruction

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

7. Management Ensure eradication and control of sepsis – Any patient with intestinal fistula and evidence of organ dysfunction (cardiac, respiratory, or renal failure) will most likely have an undrained focus of sepsis Perc drainage is least invasive means of draining collections – Catheter can be upsized – Studies can be done through tube to assess cavity Antibiotics only if there is associated cellulitis

8. Management Skin protection is essential – Effluent can be acidic or alkaline and cause skin to be excoriated – Can lead to an unmanageable wound – Can also lead to bad body image

9. Nutrition Normal energy expenditure 25 kcal/kg/day Hypoalbuminemia is a significant risk factor for mortality – Mortality rate of 42% with alb 3.5 – Nutritional support is mandatory if illness is anticipated to be longer than 10 days – Good markers are albumin, prealbumin, transferrin, and retinol binding protein “If the gut works, use it” > 75 cm of distal small bowel is required for absorption

10. Anatomy Must understand underlying pathology and anatomy to manage fistula CT Barium vs water soluble contrast Fistulogram

11. Plan Majority (80-90%) will close within 6 weeks with conservative management Fazio VW, Coutsoftides T, Steiger E. Factors influencing the outcome of treatment of small bowel cutaneous fistula. World J Surg 1983; 7:481-8. – Surgery between 10 days and 6 weeks post-op will encounter the worst adhesions Preferably wait 6 months before surgery

12. Octreotide Initially found to be beneficial in pancreatic fistulas – (Klempa et al. Prevention of postoperative pancreatic complications following duodenopancreatectomy using somatostatin, Chirurg 1979;50:427-31) Inhibits endocrine and exocrine pancreatic secretion and decreases splanchnic blood flow Additional effects include inhibition of GI hormones, GI secretions, gallbladder emptying, and gut motility May decrease the output, but not shown to aid in closure of fistulas – (Scott and Sancho)

13. Predictive factors for spontaneous closure and/or mortality FactorFavorableUnfavorable Organ of originEsophageal, Duodenal stump, Pancreatic, Biliary, Jejunal, Colonic Gastric, Lateral duodenal, Ligament of Treitz, Ileal EtiologyPostop (anast leak), Appendicitis, Diverticulitis Malignancy, IBD OutputLow (<200-500cc/day)High (>500cc/day) Nutritional statusWell nourished, Transferrin >200Malnourished, Transferrin <200 SepsisAbsentPresent State of bowelIntestinal continuity, absence of obstruction Diseased adjacent bowel, Distal obstruction, Abscess, Discontinuity, Irradiation Fistula characteristicsTract >2 cm, Defect >1cmTract 1cm MiscellaneousOriginal operation at same institution Referred from outside institution

14. Mesh use Taner T, Cima RR, Larson DW, Dozois EJ, Pemberton JH, Wolff BG. Surgical treatment of complex enterocutaneous fistulas in IBD patients using human acellular dermal matrix. Inflamm Bowel Dis. 2009 Aug;15(8):1208-12. 3 patients (27%) developed subcutaneous seroma 2 cases (18%) of superficial wound infection, all of which resolved with conservative management Mean length of hospital stay 13.5 (+/-7.2) days There were no recurrences 1 patient with Crohn's disease developed a new ECF from a separate bowel site, treated with the same surgical approach

15. Additional References Evenson AR, Fischer JE. Current Management of Enterocutaneous Fistula. J Gastrointest Surg 2006;10:455-464. Joyce MR, Dietz DW. Management of complex gastrointestinal fistula. Curr Probl Surg. 2009 May;46(5):384-430.