Enterocutaneous Fistula

Dr. Ram Prasad Subedi

PG 2nd year General Surgery
AIIMS Rishikesh
Contents
• Introduction
• Classification
• Causes of persistent ECF
• Management
• SNAP regimen
• Monitoring of ECF patient
• Prevention of ECF
Introduction
• Abnormal communication between any part of gut with skin
surface or wound is known as enterocutaneous fistula.

• Iatrogenic(75-85%) develop within 7-10 days, Spontaneously

(15 to 25%) Trauma, Malignancy, IBD, TB

• Mortality rates (5.5–33%) most common cause sepsis,

malnutrition, and fluid/ electrolyte disturbances.
• With vacuum assisted closure (VAC) and other negative pressure
wound therapies (NPWT) therapy, there are case reports of fistulae
closure well into the second and third month.
• Even in the absence of overt sepsis, 50% of patients with ECFs harbor
intra-abdominal abscesses, most of which are amenable to
percutaneous drainage
Classification of ECF
According to site, output and complexity
• Site/origin:
• Type I: Abdominal, esophageal, gastroduodenal
• Type II: Small Bowel
• Type III: Large Bowel
• Type IV: Enteroatmospheric, regardless of origin
• Output:
• Low(<200ml/24 hours)
• Moderate (200-500 ml/24 hours)
• High (>500 ml/24 hours)
• Complexity
• Simple
• Complex-Long,multiple, associated abscess,other organ involvement
(eg, bladder, vagina)
Causes of persistent ECF
• F: Foreign body
• R: Radiation enteritis
• I: IBD
• E: Epithelialized fistula tract
• N: Neoplasm
• D: Distal Obstruction
• S: Sepsis
Management of ECF

• S-N-A-P
• Stabilization, Sepsis control, Skin Care
• Nutrition
• Anatomy identification
• Plan/Procedure to deal with the fistula
 Stabilization
• Fluid and electrolyte losses with crystalloids.
• high-output ECFs will often require a urinary catheter initially.
• Severe dehydration and electrolyte disturbances will require serum
testing of renal function and electrolytes regularly.
• Daily assessment of fluid status and intake output.
Sepsis control
• Sepsis is responsible for 77% of mortality associated with ECF
• Antibiotic management should follow the Surviving Sepsis guidelines
and empiric coverage should not exceed 4 to 7 days.
• There is no role for antibiotic coverage in a patient with ECF whose
sepsis is fully controlled with percutaneous drainage
Skin Care
• Stoma bag, wound Manager, pouching system
to collect effluent
• Adhesive ring,paste,powder or hydrophilic dressing.
• NPWT
• Fistula Outpu<50 ml: Dressing and skin barrier
• Closure rates without operative intervention in the era of advanced
wound care and parenteral nutrition (TPN) vary 19 to 92%.
• 90% of spontaneous closure in the first month after sepsis resolution.
• With an additional 10% closing in 2nd and none after 2 months.
• Sepsis is responsible for 77% of mortality associated with ECF.
 Nutrition
A pt. with ECF will require 1 to 2.5 X the basal energy of a healthy adult.

Patients who consumed at least 1,500 kcal/day had 3.6-fold lower

mortality than those whose caloric intake did not achieve 1,500
kcal/ day.
 Harris-Benedict Equation

• For male
BMR = 66.47 + ( 13.75 × wt in kg ) + ( 5.003 × ht in cm ) − ( 6.755 × age in yrs )
• For female
BMR = 655.1 + ( 9.563 × wt in kg ) + ( 1.85 × ht in cm ) − ( 4.676 × age in yrs )

66.7+550+820.492-385.035 = 1052.157
Stress factor
• Caloric intake EN or PN.
• At least 20% enteric for mucosal integrity, hormonal
signaling, and immune functions of the gut tend to be
preserved.
• Fazio et al showed that mortality is 0% when serum albumin
is > 3.5 mg/dL.
Nitrogen Balance
• NB =[Protein intake (g)/6.25] - [24-hour urine urea nitrogen + 4 g + (2
g X liters output from enteric sources and wound)]
• Positive nitrogen balance signifies anabolic state.
• Negative balance implies inadequate calorie intake, excessive GI
losses, or unresolved sepsis.
Anatomy Identification
• Done by USG
• Fistulogram
• CT with oral contrast
• MRI
 High Output fistula management
1) limit intake of low sodium fluid to 500 mL/day
(2) oral solution high in sodium
(3) small volume of fluid intake with solid meals, and
(4) (PPI)/H2 receptor blocker therapy, antimotility drugs, and
octreotide
(5)Octreotide- 100-250 mcg TDs reduces fistula output by 40-60 % by
the end of 24 hours
 Plan of Fistula closure
• Non-operative: Fibrin Sealent, Endoscopic Clips, Fistula plug
• Lippert et al reported (21 were small intestine and colorectal) that
were treated with endoscopic therapies and fibrin sealant.
• These authors observed a 55.7% closure rate overall and 37%
closure rate with fibrin sealant alone
• Operative: Operative success for definitive ECF resolution ranges
from 80 to 95%.
• Failure is increased with the presence of infectious and noninfectious
complications
• following surgery, ECF recurrence is 14 to 34%.
Monitoring of ECF patient
• Monitoring Fistulas output
• Daily Urine output
• Daily Weight Daily S.electrolytes, magnesium
• Twice a week Hb and TLC Weekly Serum albumin,
prealbumin, transferrin, CRP.
Prevention of ECF
• 1. Care, Meticulous surgery to avoid iatrogenic injury to the
gut
• 2. Avoid excessive adhesiolysis
• 3. Optimize patient condition
• 4. Serosal tears should be examined carefully and repaired if
required.