Management of Enterocutaneous Fistulas

1. Management of Enterocutaneous Fistulas Jacques Heppell, MD Professor of Surgery Mayo Clinic Arizona JH0905050

3. Josef E Fisher MD

4. “Given the complex physiologic and management challenges created by postoperative enterocutaneous fistulas, use of sound surgical technique in preventing this catastrophic complication is paramount”Josef E. Fisher, 2006

5. Enterocutaneous fistulas Causes Post-operative 75-85% Others: 15-25% Inflammatory Neoplastic Post-irradiation Post-trauma

6. Post-Operative Enteric Fistulas Causes • Anastomotic disruption • Operative trauma (unrecognized) • Synthetic mesh

7. Post-operative anastomotic leaks • INCIDENCE • Recent series of 1,684 adult patients undergoing large and small intestinal anastomosis ( Mount Sinai School of Medicine) • Jan 2003 to Sept, 2005 • 38 patients had anastomotic leak • Overall leak rate of 2.3 % • DCR 2006, 49(9)

8. “Early discharge group” • Longer intensive care stay • Longer hospital stay • Higher mortality (5 %) • Fewer stoma reversed • DCR 2006,49(9)

9. Post-Operative Enteric Fistula Sepsis • Most frequent cause of death • Most frequent surgical indication • Inadequate drainage of infected area

10. Post-Operative Enteric Fistula 5 Phases of Treatment • Stabilization • Investigation • Decision • Definitive therapy • Healing

11. Stabilization (2-5 Days) • Identification • Resuscitation (crystalloid, colloid, blood) • Control of sepsis • Nutritional support • Control of fistula drainage

12. Conservative Treatment Contraindications • Peritonitis • Abscess • Bacteremia • Bleeding • Intestinal necrosis

13. Post-operative fistulas • Sepsis • Most collections can be drained externally under ultrasonographic or CT guidance

14. Investigation (7- 10 days) • Fistulography with water soluble contrast • Identify source,length,course of the fistula • Determine the nature of adjacent bowel (inflammation,stricture) • Evaluate absence or presence of bowel continuity,distal obstruction,abscess cavity

15. Spontaneous closure • Surgical etiology • Free distal flow • Healthy surrounding bowel • No abscess cavity • Fistula tract> 2 cm • Fistula tract not epithelialized • Defect < 1 cm (no discontinuity) • Low output (<500 ml/day) • No co-morbidity

16. Spontaneous closure • Good tissue 50% • Intestinal disease • Irradiation 14% • Crohn’s 8% • Neoplasia 0% • Age, sepsis, poor nutrition • Referred from outside institution • Presence of foreign body

17. Ann Plast Surg. 2006 Dec;57(6):621-5

18. Conservative Treatment • Local wound care • Avoid electrolyte imbalance • Nutritional support • Maintain patient morale

19. Psychological support • Great importance !! • Patient underwent major surgery with complication • Prolonged hospital stay • Open wound and fistula effluent has a detrimental effect on body image

20. Methods of reducing fistulas output • Restrict hypo-osmolar fluids • Encourage electrolyte mix • Antisecretory agents (PPI,Octreotide) • Antimotility agents (Loperamide,codeine)

21. Octreotide • Trial of Octreotide is worthwhile once patients have been stabilized • If significant reduction in fistula output within 3 days, octreotide should be continued

22. Post-Operative Enteric Fistula Wound Care • Important role of stomal therapist • Keep skin dry and clean • Protection against digestion • Measurement of output

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25. Pacifying the open abdomen with concomitant intestinal fistula Layton et al. The American Journal of Surgery (2010) 199, e48–e50

26. Pacifying the open abdomen with concomitant intestinal fistula Layton et al. The American Journal of Surgery (2010) 199, e48–e50

27. Pacifying the open abdomen with concomitant intestinal fistula Layton et al. The American Journal of Surgery (2010) 199, e48–e50

28. Pacifying the open abdomen with concomitant intestinal fistula Layton et al. The American Journal of Surgery (2010) 199, e48–e50

29. Wound VAC • Trial of Wound Vac is in order if wound is clean and starts to granulate • Best if open wound with some depth and no exposed mucosa

31. Wittmann Patch

32. Anchor System for Abdominal Reappoximation

34. Laparostomy • A technique for the management of intractable intra-abdominal sepsis

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39. News Ideas • Percutaneous embolisation of Gelfoam • Endoclip repair • Ethanol injection • Fasciocutaneous turnover flap • Fistuloscopy with Fibrin Glue injection • Percutaneous management

41. Fistuloscopy • An adjuvant technique for sealing gastrointestinal fistulae

42. Fibrin Glue • Endoscopic delivery of the glue • Ideal for long fistula with narrow tract

43. Failure of Conservative Treatment • Complete separation of anastomosis • Distal obstruction • Adjacent abscess • Diseased bowel • Epithelialized short tract (<2 cm) • Large intestinal opening (>1 cm) • Foreign body

44. Post-Operative Enteric Fistula • Timing of operation?

45. Post-Operative Enteric Fistula Surgical Treatment • Emergency: Peritonitis • Early (<3 weeks) • Bleeding • Bowel obstruction • Intra-abdominal abscess • Late (>6 weeks)

47. Obliterative peritonitis • No man’s land • Between 10 to 42 days • 95% of spontaneous closure occur within 4-5 weeks • “Smart” to wait at least 4 months from previous operation

48. Post-Operative Enteric Fistula Operative “Tactics” • Surgeon calm and meticulous • Decompression of proximal bowel • 2 layers anastomosis • Continuation of TPN • Antibiotics • Closure of abdominal wound

49. World J Surg 1983 vol.7 JH090505