MANAGEMENT

BY
DR RAMIZAH SHARIFF
SURGICAL ONCOLOGY
NATIONAL CANCER INSTITUTE
HOD: MR ATIKI FALFARADO
 Definition

• Abnormal communication between GI tract and

skin
• Enteroatmospheric fistula- bowel exposed
• Anatomic classification name according to organ
involved
- High pressure to low
- Aortaenteric, colovesicle, gastrocutaneous
• Physiologic classification based on output
- High-output > 500cc/24h
- Low-output < 200c /day
 Etiology of fistula classifications
• Spontaneous
• Post operative
• Congenital
• Trauma
 Etiology of fistula
• 75-90% iatrogenic
- Post operative folowing surgeries for bowel
obstruction, cancer or IBD
- Missed enetrotomy or Most often result from
anastomotic leak
- Mesh infected and/or eroded into bowel
- Patient specific versus technique specific
• Spontaneous
– IBD, malignancy, diverticulitis, appendicitis, radiation,
perforated ulcer disease or ischemic bowel
 Why so difficult?
• Usually complex problem
• Prolongs hospitilizations
• Increases Healthcare costs
• Causes distress to patient
• Require multimodal treatment approach
• High mortality rates (5-30%
 FRIEND
• Foreign body
• Radiation
• Inflammation, Infection
• Epithelization
• Neoplasm
• Distal Obstruction
 Prognosis
• Spontaneous fistula closure
- approx 30%, range from 20-80%
- 80-90% within 6 weeks
• Mortality
– overall mortality 10-20%
– mortality up to 30-35% for high output fistula
 Goals of Managements
• Fluid balance
• Sepsis control
• Electrolyte maintanance
• Nutrition status optimization
• Multidisciplinary treatment approach
• Definitive closure-spontaneous vs operative
 Pneumonic….
• S- stabilization
• S- control of sepsis
• N- nutritional support
• A-
• P-
 Diagnosis
• Through history and physical
• Imaging
• - CT scan or US to determine if fluid is draining
completely out of the body or leaking intra-
abdominally
• - Fistulogram-anatomic evaluation of fistula
location, determination of distal obstruction
• - UGI with SBFT, barium enema, endoscopy-
ancillary tests
 Nutrition Support
• Establish malnutrition via identification of 2 to 6 of the
following:
- insufficient energy intake
- weight loss
- loss of muscle mass
- loss of subcutaneous fat
- localized or generalized fluid accumulation that may
mask weight loss
- Diminished functional status as measured by grip
strength
 So when do we do what?
• PO vs NPO
- First need stable fluid balance and electrolytes
- PO diet maybe tolerated in settings of low
output ECFs
- PN may be necessary to maintain
fluid/electrolyte balance, provide nutrition to
support spontaneous closure in high output
ECFs
 Adjunct medications?
• Acid Suppressors?
- H2 receptor antagonists or PPI: decrease volume
and acidity of gastric secretion
- Sucralfate: decreases acidity and constipates
- No increase rate of fistula closure
• Somatostatin or octreatide?
- Inhibits endocrine and exocrine secretions
- No improved outcomes
• Anti-diarrheals?
- No literature to support