Enterocutaneous Fistulas 122210 Enterocutaneous Fistula An abnormal communication

Enterocutaneous Fistulas 12/22/10

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

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

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%

FRIEND • • • Foreign body Radiation Inflammation, Infection Epithelialization Neoplasm Distal obstruction

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

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

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

Nutrition • Normal energy expenditure 25 kcal/kg/day • Hypoalbuminemia is a significant risk factor for mortality – Mortality rate of 42% with alb <2. 5 vs 0% if >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

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

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

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)

Predictive factors for spontaneous closure and/or mortality Factor Favorable Unfavorable Organ of origin Esophageal, Duodenal stump, Pancreatic, Biliary, Jejunal, Colonic Gastric, Lateral duodenal, Ligament of Treitz, Ileal Etiology Postop (anast leak), Appendicitis, Malignancy, IBD Diverticulitis Output Low (<200 -500 cc/day) Nutritional status Well nourished, Transferrin >200 Malnourished, Transferrin <200 Sepsis Absent Present State of bowel Intestinal continuity, absence of obstruction Diseased adjacent bowel, Distal obstruction, Abscess, Discontinuity, Irradiation High (>500 cc/day) Fistula characteristics Tract >2 cm, Defect >1 cm Tract <1 cm, Defect >1 cm Miscellaneous Referred from outside institution Original operation at same institution

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

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.