Review on

enterocutaneous fistula
 Definition
► Enterocutaneous fistula
 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
 Leading cause, 75-85%
► Malignancy
► Infection / inflammation
 IBD, diverticulitis, appendicitis, PPU, etc
► Radiation
► Abdominal trauma
► Congenital
 Prognosis
► Mortality
 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

malnutrition Fluid and

electrolyte
disturbance
Prognostic factors on fistula closure
rate
favorable unfavorable
Esophageal, duodenal Gastric, lateral duodenal,
anatomical stump, pancreatobiliary, ileal
jejunal, colon Distal obstruction
Tract > 2cm Complex fistula / associated
Defect < 1cm abscess
Epithelialization of tract

Post-operative Malignancy
etiological Diverticulitis / appendicitis IBD
Foreign body
Radiation

Malnutrition
general 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
► Fluidand 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
► Restrictionof 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
 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
► Siteof origin of fistula
► Anatomy of fistula tract
 Complexity
 Length of tract
 Defect size
► Status of distant bowel
 Integrity
 obstruction
 Assessment of anatomy
► CT scan
 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
 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