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Background

A fistula is an abnormal communication between two epithelialized surfaces; an enterocutaneous fistula (ECF), as the name indicates, is an abnormal communication between the small or large bowel and the skin. An ECF can arise from the duodenum, jejunum, ileum, colon, or rectum. (See the image below.)

Almost healed wound around an enterocutaneous fistula.

Although fistulas arising from other regions of the gastrointestinal (GI) tract (eg, stomach and esophagus) may sometimes be included in the definition of ECF, the discussion in this article is limited to the conventional definition of ECF. A fistula-in-ano, though anatomically an ECF, conventionally is not referred to as such, because its presentation and management are different.

An ECF, which is classified as an external fistula (as opposed to an internal fistula, which is an abnormal communication between two hollow viscera), is a complication that is usually seen after surgery on the small or large bowel. In one study, about 95% of ECFs were postoperative, and the ileum was the most common site of ECF [1] ; 49% of fistulas were high-output, and 51% were low-output.

ECFs are a common presentation in general surgical wards, and despite advances in the management of these lesions, they are still responsible for a significant mortality (5-20%), due to associated sepsis, nutritional abnormalities, and electrolyte imbalances.

Understanding the pathophysiology of, as well as the risk factors for, ECFs should help to reduce their occurrence. Moreover, the well-established treatment guidelines for these lesions, along with some newer treatment options, should help clinicians to achieve a better outcome in patients with an ECF.

Treatment of ECFs continues to be a difficult task. The problems associated with an intestinal wound breakdown were mentioned as early as 53 BCE, by Celsus, who stated that “the large intestine can be sutured, not with any certain assurance, but because this doubtful hope is preferable to certain despair; for occasionally it heals up."

In the mid-19th century, John Hunter also described the difficulties in treating ECFs, insisting that "in such cases nothing is to be done but dressing the wound superficially, and when the contents of the wounded viscus become less, we may hope for a cure."

In a landmark article, Edmunds et al provided a comprehensive discussion of ECF. Of 157 patients in the study, 67 developed ECF following surgery. Important complications of ECF included fluid and electrolyte imbalance, malnutrition, and generalized peritonitis. Mortality was 62% in patients with gastric and duodenal fistulas, 54% in patients with small-bowel fistulas, and 16% with colonic fistulas.[2]

Etiology

An ECF can occur as a complication following any type of surgery on the GI tract. Indeed, more than 75% of all ECFs arise as a postoperative complication, whereas about 15-25% result from abdominal trauma or occur spontaneously in relation to cancer, irradiation, inflammatory bowel disease (IBD), or ischemic or infective conditions. The etiology of ECFs can thus be characterized as postoperative, traumatic, or spontaneous.

Postoperative

Postoperative causes of ECFs include the following:

  • 1. Disruption of anastomosis

  • 2. Inadvertent enterotomy - Occurs especially in patients with adhesions, when dissection can cause multiple serosal tears and an occasional full-thickness tear

  • 3. Inadvertent small-bowel injury - Occurs during abdominal closure, especially after ventral hernia repair

Disruption of anastomosis can result from inadequate blood flow due to an improper vascular supply, especially when extensive mesenteric vessels have to be ligated. Tension on anastomotic lines following colonic resection, restoration of continuity without adequate mobilization, or a minimal leak or infection can lead to

perianastomotic abscess formation, resulting in disruption, as seen in patients with anterior resection for rectal carcinoma. In addition, if anastomosis is performed in an unhealthy bowel (eg, diseased, ischemic), it can lead to disruption and cause an ECF.

Inadvertent picking up of the bowel during abdominal closure can result in a small-bowel fistula; this especially can occur with the use of open inlay mesh or intraperitoneal onlay mesh repair by the laparoscopic method, when the viscera comes in contact with the mesh, leading to adhesions and sometimes to disruption.

Gastroduodenal fistulas are seen most often after surgery for perforated peptic ulcer, especially in developing countries, where perforated peptic ulcer is more common. In patients with a perforated duodenal ulcer, when the perforation is large, extensive contamination is present. When the duration between the perforation and the surgery is long, there is a high possibility of a leak following surgery, leading to a lateral duodenal fistula. This problem is difficult to treat, and the mortality is high. Other causes of gastroduodenal leak include surgery for cancers of the stomach and the biliary tract.

A colocutaneous fistula can develop after colonic surgery, especially when the blood supply to a low colorectal/anal anastomosis is compromised or when there is tension at the anastomotic suture line. This type of fistula can also result from diseases of the colon, such as IBD or malignancy leading to perforation, pericolic abscess formation, and ECF. Surgery for appendicitis, appendicular perforation at the base, or drainage of an appendicular abscess can also lead to a colocutaneous fistula. Radiation therapy is also another major cause of colonic fistula. [3] In rare cases, migration of a polypropylene or composite mesh from a hernia repair can lead to ECF formation[4, 5]

Traumatic Traumatic ECF results from iatrogenic surgical trauma to the bowel that may or may not
Traumatic
Traumatic ECF results from iatrogenic surgical trauma to the bowel that may or may not be recognized. Road
traffic accidents with injury to the gut can also lead to an ECF.[6]
Spontaneous

Spontaneous causes of ECF, seen in about 15-25% of cases, include the following:

  • 4. Malignancy

  • 5. Radiation enteritis with perforation

  • 6. Intra-abdominal sepsis

  • 7. IBD (eg, Crohn disease [3] )

Ulcerative colitis (UC) can also lead to spontaneous ECF, but most cases of ECF associated with this IBD occur as a postoperative complication of restorative proctocolectomy. [7] Rarely, inadvertent incision of a malignant tumor can lead to an ECF (see the image below). In this patient, a urachal tumor was inadvertently incised when the patient underwent an appendectomy by midline incision. The patient presented with ECF (colocutaneous fistula) as the urachal tumor that ulcerated on the abdominal wall postoperatively had also infiltrated the sigmoid colon.

Postoperative malignant enterocutaneous fistula. A duodenal fistula can occur in association with a perforated duodenal ulcer,[8, 9] E ven so, the mortality is still high, in the range of 30-35%, in patients with high-output ECFs. Once a patient develops an ECF, the morbidity associated with the surgical procedure or the primary disease increases, affecting the patient's quality of life, lengthening the hospital stay, and raising the overall treatment cost. Malnutrition, sepsis, and fluid electrolyte imbalance are the primary causes of mortality in patients with an ECF. If sepsis is not controlled, progressive deterioration occurs and patients succumb to septicemia. Other sepsis- related complications include intra-abdominal abscess, soft-tissue infection, and generalized peritonitis. [10] However, patients with an ECF with favorable factors for spontaneous closure have a good prognosis and a lower mortality. Favorable factors for spontaneous closure Spontaneous closure of an ECF is determined by certain anatomic factors. Fistulas that have a good chance of healing include the following: 8. End fistulas (eg, those arising from leakage through a duodenal stump after Pólya gastrectomy) 9. Jejunal fistulas 10. Colonic fistulas 11. Continuity-maintained fistulas - These allow the patient to pass stool 12. Small-defect fistulas 13. Long-tract fistulas In addition, a fistulous tract of more than 2 cm has a higher possibility of spontaneous closure. Spontaneous closure is also possible if the bowel-wall disruption is partial and other factors are favorable. If the disruption is complete, surgical intervention is necessary to restore intestinal continuity. " id="pdf-obj-2-2" src="pdf-obj-2-2.jpg">

Postoperative malignant enterocutaneous fistula.

A duodenal fistula can occur in association with a perforated duodenal ulcer, but again, it most often arises postoperatively, resulting from a leak.

Prognosis

ECF is a common condition in most general surgical wards. Mortality has falen significantly since the late 1980s, from as high as 40-65% to as low as 5-20%, largely as a result of advances in intensive care, nutritional support, antimicrobial therapy, wound care, and operative techniques.[8, 9] Even so, the mortality is still high, in the range of 30-35%, in patients with high-output ECFs.

Once a patient develops an ECF, the morbidity associated with the surgical procedure or the primary disease increases, affecting the patient's quality of life, lengthening the hospital stay, and raising the overall treatment cost. Malnutrition, sepsis, and fluid electrolyte imbalance are the primary causes of mortality in patients with an ECF.

If sepsis is not controlled, progressive deterioration occurs and patients succumb to septicemia. Other sepsis- related complications include intra-abdominal abscess, soft-tissue infection, and generalized peritonitis.[10]

However, patients with an ECF with favorable factors for spontaneous closure have a good prognosis and a lower mortality.

Favorable factors for spontaneous closure

Spontaneous closure of an ECF is determined by certain anatomic factors. Fistulas that have a good chance of healing include the following:

  • 8. End fistulas (eg, those arising from leakage through a duodenal stump after Pólya gastrectomy)

  • 9. Jejunal fistulas

    • 10. Colonic fistulas

    • 11. Continuity-maintained fistulas - These allow the patient to pass stool

    • 12. Small-defect fistulas

    • 13. Long-tract fistulas

In addition, a fistulous tract of more than 2 cm has a higher possibility of spontaneous closure. Spontaneous closure is also possible if the bowel-wall disruption is partial and other factors are favorable. If the disruption is complete, surgical intervention is necessary to restore intestinal continuity.

Unfavorable factors for spontaneous closure

When an ECF is associated with adverse factors, then spontaneous closure does not commonly occur, and surgical intervention, despite its associated risks, is frequently required. In these patients, the outcome is less likely to be good.[11]

Factors preventing the spontaneous closure of an ECF can be remembered by using the acronym FRIEND, which represents the following[12] :

  • 14. Foreign body

  • 15. Radiation

  • 16. Inflammation/infection/IBD

  • 17. Epithelialization of the fistula tract

  • 18. Neoplasm

  • 19. Distal obstruction - A distal obstruction prevents the spontaneous closure of an ECF, even in the presence of other favorable factors; if present, surgical intervention is needed to relieve the obstruction

In addition, lateral duodenal, ligament of Treitz, and ileal fistulas have less tendency to spontaneously close.[10]

Excoriation

Skin excoriation (see the image below) is one of the complications that can lead to significant morbidity in patients with ECF. When the enteric contents are more fluid than solid, this becomes a difficult problem; the skin excoriation makes it difficult to put a collecting bag or dressings over the fistula, and more leakage leads to an increase in the excoriation.

Unfavorable factors for spontaneous closure When an ECF is associated with adverse factors, then spontaneous closure[11] Factors preventing the spontaneous closure of an ECF can be remembered by using the acronym FRIEND, which represents the followin g [12] : 14. F oreign body 15. R adiation 16. I nflammation/infection/IBD 17. E pithelialization of the fistula tract 18. N eoplasm 19. D istal obstruction - A distal obstruction prevents the spontaneous closure of an ECF, even in the presence of other favorable factors; if present, surgical intervention is needed to relieve the obstruction In addition, lateral duodenal, ligament of Treitz, and ileal fistulas have less tendency to spontaneously close. [10] Excoriation Skin excoriation (see the image below) is one of the complications that can lead to significant morbidity in patients with ECF. When the enteric contents are more fluid than solid, this becomes a difficult problem; the skin excoriation makes it difficult to put a collecting bag or dressings over the fistula, and more leakage leads to an increase in the excoriation. Enterocutaneous fistula with severe skin excoriation. History and Physical Examination Features suggestive of an enterocutaneous fistula (ECF) include postoperative abdominal pain, tenderness, distention, enteric contents from the drain site, and the main abdominal wound. Tachycardia and pyrexia may also be present, as may signs of localized or diffuse peritonitis, including guarding, rigidity, and rebound tenderness. The type of ECF, as based on the output of the enteric contents, also determines the patient's health status and how the patient may respond to therapy. ECFs are usually classified into three categories, as follows [3] :  Low-output fistula (<200 mL/day),  Moderate-output fistula (200-500 mL/day)  High-output fistula (>500 mL/day) Complications Patients with ECF present with associated complications, such as sepsis, fluid and electrolyte abnormalities, and malnutrition. " id="pdf-obj-3-49" src="pdf-obj-3-49.jpg">

Enterocutaneous fistula with severe skin excoriation.

History and Physical Examination

Features suggestive of an enterocutaneous fistula (ECF) include postoperative abdominal pain, tenderness, distention, enteric contents from the drain site, and the main abdominal wound. Tachycardia and pyrexia may also be present, as may signs of localized or diffuse peritonitis, including guarding, rigidity, and rebound tenderness.

The type of ECF, as based on the output of the enteric contents, also determines the patient's health status and how the patient may respond to therapy. ECFs are usually classified into three categories, as follows [3] :

Low-output fistula (<200 mL/day),

Moderate-output fistula (200-500 mL/day)

High-output fistula (>500 mL/day)

Complications

Patients with ECF present with associated complications, such as sepsis, fluid and electrolyte abnormalities, and malnutrition.

The degree of sepsis depends on the state of the ECF. If the fistula forms a direct tract through which the bowel contents are draining onto the skin, then the sepsis may be minimal, whereas if the fistula forms an indirect tract through which the bowel contents are draining into an abscess cavity and then onto the skin, the degree of sepsis may be higher. In the presence of extensive peritoneal contamination or generalized peritonitis with ECF, the patient can be toxic due to severe sepsis.

Leakage of protein-rich enteric contents, intra-abdominal sepsis, or electrolyte imbalance–related paralytic ileus, as well as a general feeling of ill health, leads to reduced nutritional intake by these patients, resulting in malnutrition. Nearly 70% of patients with ECFs may have malnutrition, and it is a significant prognostic factor for spontaneous fistula closure.[13]

Sepsis, malnutrition, and electrolyte imbalance are the predominant factors that lead to death in patients with ECF. [14] Rarely, intestinal failure can occur as one of the complications of ECF, which results in significant morbidity and mortality.[15]

A high-output fistula increases the possibility of fluid and electrolyte imbalance and malnutrition.

Laboratory Studies

The following laboratory studies are performed in the evaluation of an enterocutaneous fistula (ECF):

Total leukocyte count - This is important because sepsis can lead to leukocytosis

Serum sodium, potassium, and chloride levels - Electrolyte abnormalities can result from

fluid and electrolyte loss Complete blood count (CBC), total proteins, serum albumin, and globulin - These can

demonstrate the presence of malnutrition-associated anemia/hypoalbuminemia Serum transferrin - Low levels (<200 mg/dL) are a predictor of poor healing

Serum C-reactive protein - Levels may be elevated

Imaging Studies

Fistulography

During fistulography (see the images below), a water-soluble contrast is injected into the fistulous tract.

The degree of sepsis depends on the state of the ECF. If the fistula forms a[13] Sepsis, malnutrition, and electrolyte imbalance are the predominant factors that lead to death in patients with ECF . [14] R arely, intestinal failure can occur as one of the complications of ECF, which results in significant morbidity and mortality . [15] A high-output fistula increases the possibility of fluid and electrolyte imbalance and malnutrition. Laboratory Studies The following laboratory studies are performed in the evaluation of an enterocutaneous fistula (ECF):  Total leukocyte count - This is important because sepsis can lead to leukocytosis  Serum sodium, potassium, and chloride levels - Electrolyte abnormalities can result from  fluid and electrolyte loss Complete blood count (CBC), total proteins, serum albumin, and globulin - These can  demonstrate the presence of malnutrition-associated anemia/hypoalbuminemia Serum transferrin - Low levels (<200 mg/dL) are a predictor of poor healing  Serum C-reactive protein - Levels may be elevated Imaging Studies Fistulography During fistulography (see the images below), a water-soluble contrast is injected into the fistulous tract. Fistulogram showing enterocutaneous fistula. " id="pdf-obj-4-58" src="pdf-obj-4-58.jpg">

Fistulogram showing enterocutaneous fistula.

The degree of sepsis depends on the state of the ECF. If the fistula forms a[13] Sepsis, malnutrition, and electrolyte imbalance are the predominant factors that lead to death in patients with ECF . [14] R arely, intestinal failure can occur as one of the complications of ECF, which results in significant morbidity and mortality . [15] A high-output fistula increases the possibility of fluid and electrolyte imbalance and malnutrition. Laboratory Studies The following laboratory studies are performed in the evaluation of an enterocutaneous fistula (ECF):  Total leukocyte count - This is important because sepsis can lead to leukocytosis  Serum sodium, potassium, and chloride levels - Electrolyte abnormalities can result from  fluid and electrolyte loss Complete blood count (CBC), total proteins, serum albumin, and globulin - These can  demonstrate the presence of malnutrition-associated anemia/hypoalbuminemia Serum transferrin - Low levels (<200 mg/dL) are a predictor of poor healing  Serum C-reactive protein - Levels may be elevated Imaging Studies Fistulography During fistulography (see the images below), a water-soluble contrast is injected into the fistulous tract. Fistulogram showing enterocutaneous fistula. " id="pdf-obj-4-62" src="pdf-obj-4-62.jpg">

Fistulogram showing a colocutaneous fistula following anastomotic leak after colostomy closure.

Fistulography is conventionally performed 7-10 days after the presentation of an ECF and provides the following information:

Length of the tract

Extent of the bowel-wall disruption

Location of the fistula

Presence of a distal obstruction

 

Water-soluble contrast enema

 

The different types of tracts that can be seen by using a water-soluble contrast enema (WCE) in patients with ECF with failure of low colorectal anastomosis may be classified as follows [16] :

I – Simple, short blind ending, <2 cm

 

II - Continuous linear, long single, >2 cm

III - Continuous complex, multiple linear

 

Tract positions are as follows:

 

Anterior - Ventral, 10-o’clock to 2-o’clock position

Posterior - Dorsal, 4-o’clock to 8-o’clock position

Lateral - Right (2-o’clock to 4-o’clock position) or left (8-o’clock to 10-o’clock position)

Additional tract features seen with a WCE include the cavity (pooling of contrast within space) and/or a stricture (narrowing of anastomosis, with hold of contrast). The presence of a stricture and a large cavity on WCE predicts failure of healing.

Computed tomography

Computed tomography (CT) is useful for demonstrating intra-abdominal abscess cavities. Such cavities can occur if an ECF has an indirect tract when it first drains into an abscess cavity and then drains to the exterior cavity. If an ECF is associated with intra-abdominal sepsis, then interloop abscesses may be present.

Other Tests

Oral administration of a nonabsorbable marker (eg, charcoal, Congo red) can help confirm the presence of an ECF.

Methylene blue diluted in saline can be administered through a nasogastric tube as a simple bedside test to confirm the presence of an ECF, especially in patients with a gastrocutaneous or lateral duodenal fistula. This test can also help to determine whether the leak is from a segment that is in the continuity of the gastrointestinal tract, especially in the case of proximal fistulas. However, because methylene blue loses diagnostic efficacy as it becomes diluted with intestinal secretions, its role in identifying distal ECFs is limited.

Approach Considerations

The conventional therapy for an enterocutaneous fistula (ECF) in the initial phase is always conservative. Immediate surgical therapy on presentation is contraindicated, because the majority of

ECFs spontaneously close as a result of conservative therapy. Surgical intervention in the presence of sepsis and poor general condition would be hazardous for the patient.

However, patients with an ECF with adverse factors, such as a lateral duodenal fistula, an ileal fistula, a high-output fistula, or a fistula associated with a diseased bowel, may require early surgical intervention.

Conservative Therapy

Conservative treatment should usually be administered for a period ranging from a few weeks to a few months. The principles of nonsurgical therapy for ECFs include the following:

Rehydration

Administration of antibiotics

Correction of anemia

Electrolyte repletion

Drainage of obvious abscess

Nutritional support

Control of fistula drainage

Skin protection

With the above-mentioned supportive therapy, spontaneous closure occurs in almost 70% of patients. In a study of 186 patients, Reber et al found that 91% of small-bowel fistulas that closed spontaneously did so within 1 month after sepsis was cured. The remaining fistulas that closed spontaneously did so by the end of 3 months after sepsis cure, with the rest of the lesions requiring surgical closure.[17]

Uba et al reported that the majority of ECFs in children closed spontaneously following high-protein and high-carbohydrate nutrition. [18] They found that hypoalbuminemia and jejunal location were important variables resulting in nonspontaneous closure, whereas hypokalemia, sepsis, and hypoproteinemia/hypoalbuminemia were risk factors for high mortality in children with ECF.

Rehydration, electrolyte repletion, and nutritional support

Common fluid and electrolyte problems that must be corrected in patients with an ECF include the following:

Dehydration

The author uses parenteral nutrition more often in patients with a proximal small-bowel ECF, especially if it is in the proximal jejunum, or with a high-output fistula. In patients with a distal ECF, the author prefers to use enteral nutrition whenever possible.

Studies have shown that the provision of only 20% of calories fed enterally may protect the integrity of the mucosal barrier, as well as the immunologic and hormonal function of the gut. [10] Hence, a combination of parenteral and enteral nutrition can be used. In high-output fistulas, the author uses this combination therapy.

In patients with a proximal fistula, if a nasojejunal tube can be introduced beyond the site of the fistula, then these patients can be supported with enteral nutrition, provided that there is at least 4-5 ft (1.2-1.5 m) of small bowel distal to it and no distal obstruction. Patients with chronic small-bowel ECFs may need additional supplementation with copper, folic acid, and vitamin B12.[10]

Total parenteral nutrition

Total parenteral nutrition (TPN) is usually indicated with suspected gastric, duodenal, or small-bowel fistula. When the fistula output is very high, discontinuance of oral intake is recommended because oral intake stimulates further losses of fluids, electrolytes, and protein via the fistula. A decrease in fistula output frequently occurs with the initiation of TPN.

Water requirements for TPN are 1 mL/kcal/day. Electrolyte requirements for TPN are as follows:

Sodium (Na) - 80-100 mEq/day

Potassium (K) - 75-100 mEq/day

Magnesium (Mg) - 15-20 mEq/day

Calcium (Ca) - 15-20 mEq/day

Calorie and protein requirements are as follows:

Maintenance – 25-30 kcal, 1.0-1.2 g/kg/day

Moderate stress – 30-40 kcal, 1.3-1.4 g/kg/day

Severe stress – 40-45 kcal, 1.5-2.0 g/kg/day

Protein (g)/6.25 should equal nitrogen (g), and the nonprotein calorie-to-nitrogen ratio should be as follows:

Maintenance - 200-300:1

Moderate stress - 150:1

Severe stress - <100:1

A standard, general purpose formula for TPN consists of the following:

Glucose, 75 g

Amino acids, 20 g

Lipids, 30 g/L

The introduction of ethyl vinyl acetate bags has made the admixture of fat emulsion with dextrose and amino acids possible (3-in-1 concept). [19] This leads to a more uniform administration of a balanced solution containing the three macronutrients plus micronutrients over a 24-hour period.

Enteral nutrition

Enteral nutrition is the mainstay of treatment for patients with ECFs. In fistulas of the distal ileum, colon, or duodenum, enteral nutrition should be considered and can be administered via various routes. Conventionally, when a gastroduodenal anastomosis or closure is needed in adverse conditions, a concomitant feeding jejunostomy is performed, so that access is available for enteral nutritional support in case of an anastomotic leak.

The other routes of administration can be via nasogastric/jejunal tubes or a gastrostomy. High rates of feeding should be avoided to prevent hyperosmolar diarrhea. Elemental diets, that is, nonresidue

balanced diets with protein components reduced to their basic elements, are preferred. When a tube enterostomy is performed, proper fixation is necessary to prevent complications, such as dislodgement of the tube or antegrade migration in the gastrointestinal (GI) tract.[20]

Fistuloclysis

Enteral nutrition can also be administered in patients with high-output proximal jejunocutaneous or ileocutaneous fistulas with good mucocutaneous continuity. Feeding can be administered through a feeding tube inserted in the distal limb of the ECF. Teubner et al and Ham et al have reported good results with this method in select patients to improve the nutrition of the patient, which is helpful for subsequent fistula closure and promotes healing of the fistula. [21, 22, 23] An interprofessional approach is needed.[24]

Skin management

Irrgang et al developed a fistula assessment guide that has aided skin management related to ECFs [25] This guide is based on the following characteristics:

Origin of fistula

Nature of effluent

Condition of skin

Location of fistula opening

For a high-output fistula, a pouch system is preferable to a conventional skin dressing. For a low- output fistula, a skin barrier with a dressing or pouch is advocated.

The degree of skin irritation present (from erythema to maceration to skin loss) guides the type of skin- protecting agents that should be applied and the type of pouch system that should be used. In addition, an important consideration is whether the opening is flush with the skin, retracted and deep, close to bony prominences, or in an open wound.

Pouches used for skin care

When the fistula output is high, it is desirable to use a pouch for collecting the enteric effluents. Ostomy pouches in one- or two-piece designs with either a drainable clip or a urostomy-type closure can be cut and fit to perifistular skin. If the area of the fistula is on an irregular body contour (eg, close to bony prominences), then a one-piece pouch is more suitable because it can adhere better.

A transparent pouch is preferred to an opaque pouch, for visualization of the fistula. A pouch with a skin-barrier backing is more durable than one with an adhesive backing. Wound manager bags (see the image below) are preferable in that they are specifically designed to help make wound care easier with good skin protection and access to the wound for its care.

balanced diets with protein components reduced to their basic elements, are preferred. When a tube enterostomy[20] Fistuloclysis Enteral nutrition can also be administered in patients with high-output proximal jejunocutaneous or ileocutaneous fistulas with good mucocutaneous continuity. Feeding can be administered through a feeding tube inserted in the distal limb of the ECF. Teubner et al and Ham et al have reported good results with this method in select patients to improve the nutrition of the patient, which is helpful for subsequent fistula closure and promotes healing of the fistula. [21, 22, 23] An interprofessional approach is needed. [24] Skin management Irrgan g et al developed a fistula assessment guide that has aided skin management related to ECF s [25] This guide is based on the following characteristics:  Origin of fistula  Nature of effluent  Condition of skin  Location of fistula opening For a high-output fistula, a pouch system is preferable to a conventional skin dressing. For a low- output fistula, a skin barrier with a dressing or pouch is advocated. The degree of skin irritation present (from erythema to maceration to skin loss) guides the type of skin- protecting agents that should be applied and the type of pouch system that should be used. In addition, an important consideration is whether the opening is flush with the skin, retracted and deep, close to bony prominences, or in an open wound. Pouches used for skin care When the fistula output is high, it is desirable to use a pouch for collecting the enteric effluents. Ostomy pouches in one- or two-piece designs with either a drainable clip or a urostomy-type closure can be cut and fit to perifistular skin. If the area of the fistula is on an irregular body contour (eg, close to bony prominences), then a one-piece pouch is more suitable because it can adhere better. A transparent pouch is preferred to an opaque pouch, for visualization of the fistula. A pouch with a skin-barrier backing is more durable than one with an adhesive backing. Wound manager bags (see the image below) are preferable in that they are specifically designed to help make wound care easier with good skin protection and access to the wound for its care. Wound manager. " id="pdf-obj-8-56" src="pdf-obj-8-56.jpg">

Wound manager.

Skin barriers

Powder, paste, wafers, spray, and creams are used as skin barriers for the protection of skin from the enteric effluents.

Pectin-based wafers that melt and seal with the skin provide a good barrier and offer protection for a variable period before the skin breaks down and ulcerates. In low-output fistulas, absorbent dressings can be put on top of the skin-barrier wafer to absorb any effluent overflow. The skin wafer protects the adjoining skin from erythema and maceration.

Pectin- or karaya-based powders and paste are used. Powders are preferred over a paste in wet, weepy, perifistular skin when severe skin maceration is present. A generous amount of powder should be used and continuously added for good results. In patients with weepy skin and a high-output fistula, management becomes difficult.

A spray provides a protective film and is helpful for pouching, but it might not be beneficial if used alone.

Zinc creams (see the images below) are used to waterproof and protect the skin. Again, a generous amount with continuous replacement is necessary because the cream is washed away with discharging enteric effluents.

Skin barriers Powder, paste, wafers, spray, and creams are used as skin barriers for the protection[26] Intubation of fistulous tract with drain. " id="pdf-obj-9-14" src="pdf-obj-9-14.jpg">
Skin barriers Powder, paste, wafers, spray, and creams are used as skin barriers for the protection[26] Intubation of fistulous tract with drain. " id="pdf-obj-9-16" src="pdf-obj-9-16.jpg">

Zinc oxide cream for skin protection.

Zinc oxide cream barrier around enterocutaneous fistula, with the fistula opening seen.

Control of fistula drainage

The fistula tract is intubated with a drain (see the image below). Volume depletion from a proximal high-output fistula can be controlled with the use of the long-acting somatostatin analogue octreotide, which acts by inhibiting GI hormones. The administration of octreotide reportedly diminishes fistula output, but whether it shortens the time required for fistula closure remains to be determined.[26]

Skin barriers Powder, paste, wafers, spray, and creams are used as skin barriers for the protection[26] Intubation of fistulous tract with drain. " id="pdf-obj-9-28" src="pdf-obj-9-28.jpg">

Intubation of fistulous tract with drain.

Draus et al recommended a 3-day trial of octreotide, maintaining that if the fistula output is reduced during this time, then administration of the drug should be continued. [27] (Octreotide use is associated with an increased incidence of cholelithiasis. [10] ) Two meta-analyses showed that somatostatin and its analogues decreased the time for fistula closure and increased the closure rate.[28, 29]However, there was no significant change in the mortality with the use of somatostatin or its analogues.

Hyon et al reported on a vacuum-sealing method to reduce output, in which a semipermeable barrier was created over the fistula by vacuum packing a synthetic, hydrophobic polymer covered with a self- adherent surgical sheet. To set up the system, the investigators built a vacuum chamber equipped with precision instruments; the chamber supplied subatmospheric pressures of 350-450 mm Hg. The pressure reduced the daily fistula output from 800 mL to about 10 mL, thus restoring bowel transit and

physiology.[30]

Draus et al reported that the use of a vacuum-assisted closure (VAC) system for wounds, which consisted of an evacuation tube embedded in a polyurethane foam dressing, helped improve the condition of the wound, prevented skin excoriation, and promoted wound contracture and healing.[27,

31]

Electrical nerve stimulation

Electrical nerve stimulation (ENS) increases blood flow in ischemic tissues and encourages healing. Berna et al reported the successful use of ENS in two patients with a low-output ECF. In the study, the direction and depth of the fistula tract were ultrasonographically determined. A sterile compress impregnated with saline solution was then introduced through the fistula. The positive electrode was positioned on the compress, and the negative electrode was positioned over the fistula orifice.[32]

The treatment was given once daily for 1 hour, with one patient requiring 10 treatment sessions to heal and the second patient requiring 20 sessions. ENS was well tolerated by both patients, and no complications were noted. No recurrence of the fistula developed over a 3-year follow-up period.

Surgical Therapy

Indications for surgery

Patients who an ECF with adverse factors may require earlier surgical intervention. These adverse factors include the following:

Lateral duodenal or ligament of Treitz fistula

Ileal fistula

High-output fistula

Fistula associated with diseased bowel, distal obstruction, or eversion of mucosa (see the image below)

Draus et al recommended a 3-day trial of octreotide, maintaining that if the fistula output isg should be continued. [27] (Octreotide use is associated with an increased incidence of cholelithiasis. [10] ) Two meta-analyses showed that somatostatin and its analogues decreased the time for fistula closure and increased the closure rate. [28, 29] However, there was no significant change in the mortality with the use of somatostatin or its analogues. Hyon et al reported on a vacuum-sealing method to reduce output, in which a semipermeable barrier was created over the fistula by vacuum packing a synthetic, hydrophobic polymer covered with a self- adherent surgical sheet. To set up the system, the investigators built a vacuum chamber equipped with precision instruments; the chamber supplied subatmospheric pressures of 350-450 mm Hg. The pressure reduced the daily fistula output from 800 mL to about 10 mL, thus restoring bowel transit and physiology . [30] Draus et al reported that the use of a vacuum-assisted closure (VAC) system for wounds, which consisted of an evacuation tube embedded in a polyurethane foam dressing, helped improve the condition of the wound, prevented skin excoriation, and promoted wound contracture and healing. [27, 31] Electrical nerve stimulation Electrical nerve stimulation (ENS) increases blood flow in ischemic tissues and encourages healing. Berna et al reported the successful use of ENS in two patients with a low-output ECF. In the study, the direction and depth of the fistula tract were ultrasonographically determined. A sterile compress impregnated with saline solution was then introduced through the fistula. The positive electrode was positioned on the compress, and the negative electrode was positioned over the fistula orifice. [32] The treatment was given once daily for 1 hour, with one patient requiring 10 treatment sessions to heal and the second patient requiring 20 sessions. ENS was well tolerated by both patients, and no complications were noted. No recurrence of the fistula developed over a 3-year follow-up period. Surgical Therapy Indications for surgery Patients who an ECF with adverse factors may require earlier surgical intervention. These adverse factors include the following:  Lateral duodenal or ligament of Treitz fistula  Ileal fistula  High-output fistula  Fistula associated with diseased bowel, distal obstruction, or eversion of mucosa (see the image below) Eversion of mucosa in an enterocutaneous fistula, an unfavorable condition for spontaneous closure. " id="pdf-obj-10-62" src="pdf-obj-10-62.jpg">

Eversion of mucosa in an enterocutaneous fistula, an unfavorable condition for spontaneous closure.

Enteroatmospheric fistula (EAF), a special subset of ECF, is defined as a communication between the GI tract and the atmosphere. [33] It can occur as a complication of "damage control" laparotomy (DCL) and results in significant morbidity and mortality. The etiology is complex and ranges from persistent abdominal infection, anastomotic dehiscence, and adhesions of the bowel to fascia with a laparostoma.

Because EAFs almost never close spontaneously, definitive repair usually requires major surgical intervention. Complex abdominal-wall reconstruction immediately after fistula resection is necessary for all EAFs once the infection has subsided, which may be 6-12 months after the original insult. [34] A “fistula patch” technique has also been reported for protecting open abdominal wounds from being contaminated by intestinal fistulae drainage, while and simultaneously applying enteral nutrition.[35]

Because the possibility of spontaneous closure is reduced in patients with adverse factors, surgical intervention should be undertaken after a 4- to 6-week trial of conservative therapy, if no signs of spontaneous closure exist. Surgical procedures in patients with adverse factors can include draining an abscess, creating stomas by exteriorizing the bowel, or creating controlled fistulas. When feasible, resection of the fistula with restoration of GI continuity is performed.

In patients with no associated adverse factors, the author usually waits for about 3-4 months before planning surgical therapy for an ECF.

Surgical therapy [36, 37] should be undertaken in patients with conventional fistulas without any adverse factors if the patient is stable, free from all sources of sepsis, and can withstand the resectional procedure needed for fistula closure. [10] It is also important that it be technically feasible to perform the procedure without posing a very high risk of injury to the bowel or other important structures. Patients with an almost completely healed wound with a fistulous opening (shown below) have a good chance of responding to surgical therapy.

Enteroatmospheric fistula (EAF <a href=) , a special subset of ECF, is defined as a communication between the GI tract and the atmosphere. [33] It can occur as a complication of "damage control" laparotomy (DCL) and results in significant morbidity and mortality. The etiology is complex and ranges from persistent abdominal infection, anastomotic dehiscence, and adhesions of the bowel to fascia with a laparostoma. Because EAFs almost never close spontaneously, definitive repair usually requires major surgical intervention. Complex abdominal-wall reconstruction immediately after fistula resection is necessar y for all EAFs once the infection has subsided, which may be 6-12 months after the original insult. [34] A “fistula patch” technique has also been reported for protecting open abdominal wounds from bein g contaminated by intestinal fistulae drainage, while and simultaneously applying enteral nutrition. [35] Because the possibility of spontaneous closure is reduced in patients with adverse factors, surgical intervention should be undertaken after a 4- to 6-week trial of conservative therapy, if no signs of spontaneous closure exist. Surgical procedures in patients with adverse factors can include draining an abscess, creating stomas by exteriorizing the bowel, or creating controlled fistulas. When feasible, resection of the fistula with restoration of GI continuity is performed. In patients with no associated adverse factors, the author usually waits for about 3-4 months before planning surgical therapy for an ECF. Surgical therap y [36, 37] s hould be undertaken in patients with conventional fistulas without any adverse factors if the patient is stable, free from all sources of sepsis, and can withstand the resectional procedure needed for fistula closure. [10] It is also important that it be technically feasible to perform the procedure without posing a very high risk of injury to the bowel or other important structures. Patients with an almost completely healed wound with a fistulous opening (shown below) have a good chance of responding to surgical therapy. enterocutaneous fistula. Fistula tract being excised. Operative details Almost healed wound around an In addition to ensuring that patients are stable and free from sources of sepsis before surgical correction of an ECF is undertaken, antibiotic prophylaxis should be performed and parenteral nutritional supplementation provided as necessary during the preoperative and the perioperative periods to achieve good results. Enteral feeding should be decreased to allow luminal antibiotic preparation. Antibiotic therapy should be administered after the culture sensitivity of earlier-grown organisms has been checked. [10] Incision " id="pdf-obj-11-30" src="pdf-obj-11-30.jpg">

enterocutaneous fistula.

Fistula tract being excised.

Operative details

Enteroatmospheric fistula (EAF <a href=) , a special subset of ECF, is defined as a communication between the GI tract and the atmosphere. [33] It can occur as a complication of "damage control" laparotomy (DCL) and results in significant morbidity and mortality. The etiology is complex and ranges from persistent abdominal infection, anastomotic dehiscence, and adhesions of the bowel to fascia with a laparostoma. Because EAFs almost never close spontaneously, definitive repair usually requires major surgical intervention. Complex abdominal-wall reconstruction immediately after fistula resection is necessar y for all EAFs once the infection has subsided, which may be 6-12 months after the original insult. [34] A “fistula patch” technique has also been reported for protecting open abdominal wounds from bein g contaminated by intestinal fistulae drainage, while and simultaneously applying enteral nutrition. [35] Because the possibility of spontaneous closure is reduced in patients with adverse factors, surgical intervention should be undertaken after a 4- to 6-week trial of conservative therapy, if no signs of spontaneous closure exist. Surgical procedures in patients with adverse factors can include draining an abscess, creating stomas by exteriorizing the bowel, or creating controlled fistulas. When feasible, resection of the fistula with restoration of GI continuity is performed. In patients with no associated adverse factors, the author usually waits for about 3-4 months before planning surgical therapy for an ECF. Surgical therap y [36, 37] s hould be undertaken in patients with conventional fistulas without any adverse factors if the patient is stable, free from all sources of sepsis, and can withstand the resectional procedure needed for fistula closure. [10] It is also important that it be technically feasible to perform the procedure without posing a very high risk of injury to the bowel or other important structures. Patients with an almost completely healed wound with a fistulous opening (shown below) have a good chance of responding to surgical therapy. enterocutaneous fistula. Fistula tract being excised. Operative details Almost healed wound around an In addition to ensuring that patients are stable and free from sources of sepsis before surgical correction of an ECF is undertaken, antibiotic prophylaxis should be performed and parenteral nutritional supplementation provided as necessary during the preoperative and the perioperative periods to achieve good results. Enteral feeding should be decreased to allow luminal antibiotic preparation. Antibiotic therapy should be administered after the culture sensitivity of earlier-grown organisms has been checked. [10] Incision " id="pdf-obj-11-38" src="pdf-obj-11-38.jpg">

Almost healed wound around an

In addition to ensuring that patients are stable and free from sources of sepsis before surgical correction of an ECF is undertaken, antibiotic prophylaxis should be performed and parenteral nutritional supplementation provided as necessary during the preoperative and the perioperative periods to achieve good results. Enteral feeding should be decreased to allow luminal antibiotic preparation. Antibiotic therapy should be administered after the culture sensitivity of earlier-grown organisms has been checked.[10]

Incision

When performing surgery for an ECF, the author makes a point of always entering the abdomen through a fresh incision, given that there is a possibility of the gut being adherent to the site of the incision of the index operation. If the native incision follows a supraumbilical midline route, then the author takes an infraumbilical midline route and then extends it to the operative site.

If it is in the middle portion of the midline, then the author makes either an incision in the midline superior or inferior to the native incision or a transverse incision to approach the abdomen. The author always enters the peritoneal cavity in a relatively virgin area to lessen the chance of an inadvertent enterotomy.

Excision and restoration of bowel continuity

Once an assessment is made in the peritoneal cavity, then the entire bowel from the ligament of Treitz to the rectum is made free of all adhesions. Once this is achieved, the fistulous site is dissected free from the surrounding structures, and a complete excision is done. The author prefers to restore bowel continuity by using a two-layer anastomosis, employing interrupted nonabsorbable suture of healthy and well-vascularized bowel. The author uses it for small-bowel, as well as large-bowel, anastomosis.

An inner layer consisting of continuous absorbable suture and an outer layer consisting of interrupted nonabsorbable sutures can also be used to restore bowel continuity. Other alternatives include the use of staplers, especially in low colorectal anastomoses.

Treatment of abscess or diseased bowel

If an abscess or diseased bowel segments are seen, then drainage of the abscess or resection of the diseased bowel is performed. [9] If the patient is too sick to tolerate a resectional procedure, then exteriorization of the bowel via ileostomy or colostomy is carried out.

Roux-en-Y drainages or a serosal patch can sometimes be used, especially for a lateral duodenal fistula following a leak after simple closure of a perforated duodenal ulcer. [10] However, the results of these procedures are not very encouraging. Converting a lateral duodenal fistula into an end fistula with a tube duodenostomy is a good option but may not be possible in most patients.

If anastomosis is performed close to a duodenojejunal flexure, then adequate decompression by gastrostomy and feeding jejunostomy are carried out. The latter is also performed when proximal fistula repair is undertaken (eg, lateral duodenal fistula).

Myocutaneous or fasciocutaneous flap

De Weerd et al described the use of a sandwich-design myocutaneous flap cover to close a high- output ECF. [38] In the initial phase of treatment, the authors used a VAC system for wound care to promote the development of granulation tissue around the fistulous opening. The fistula was then closed with serratus muscle from a composite free latissimus dorsi–serratus flap. The large abdominal wall defect was closed with the musculocutaneous latissimus dorsi flap taken from the composite flap. The placement of a VAC system between the serratus and the latissimus dorsi helped to fix the serratus to the fistula.

Successful direct repair of an ECF using a surrounding fasciocutaneous flap has also been reported.

Postoperative care

In the postoperative phase of surgical therapy for an ECF, good nutritional status is essential, because healing of the tissue and anastomosis depends on it.

Antibiotic coverage is needed if the operation is performed in the presence of sepsis. Any flare-up of sepsis increases the possibility of breakdown of the anastomosis and of the abdominal wall closure (leading to dehiscence). However, unnecessary use of antibiotics can lead to resistance and should therefore be avoided.

Fluid and electrolyte balance with appropriate correction is also important, especially in patients with adverse factors (eg, high-output fistula).

Patients who develop spontaneous fistula due to disease need appropriate therapy (eg, infliximab for Crohn disease or antituberculous therapy for tuberculosis) during follow-up to prevent disease recurrence or recurrence of the ECF. [40] In patients with a malignancy-related ECF, appropriate chemotherapy and radiation, if required, are administered to control the primary disease.

After healing of a conventional fistula by spontaneous closure, patients should be informed that because healing occurs with secondary intention, there is a possibility of development of an incisional hernia as a long-term complication of ECF.

Other Interventions

Use of fibrin glue and plugs

In a study of 10 patients with low-output (n=7) or high-output (n=3) ECFs that had failed to close after conservative therapy, Rabago et al observed that fibrin glue completely sealed the majority of ECFs. [41] Once a fistula had been endoscopically located, 2-4 mL of reconstituted fibrin glue (Tissucol 2.0 at 37°C) was injected through a catheter. The patients required a mean 2.5 treatment sessions (range, 1- 5 sessions), and the mean healing time was 16 days (range, 5-40 days). After treatment, 87.5% of the low-output fistulas and 55% of the high-output fistulas sealed completely. No complications occurred.

Truong et al described the use of a Vicryl plug in combination with fibrin glue in the treatment of ECFs. [42] After the site of an ECF or anastomotic leak was endoscopically sealed with the plug and glue, seven of the study's nine patients healed completely.

In another study, however, when fibrin glue was introduced directly into an ECF through the fistula opening in the skin, the results were not encouraging, with the fistula healing in only one out of eight

patients.[27]

Autologous platelet-rich fibrin glue also has been reported to be safe and effective in the treatment of low-output ECFs by reducing the closure time and promoting closure.[43]

Good results with endoscopic therapy suggest that this technique, when possible, can be used when other conservative methods fail.

Successful closure of a duodenocutaneous fistula has been reported with the use of the Biodesign enterocutaneous fistula plug (Cook Medical, Bloomington, IN),which is derived from a biologic plug used in fistula-in-ano tracts. The plug is introduced into the fistulous tract percutaneously.[44]

Gelfoam embolization

Lisle et al described successful treatment of three cases of ECF with embolization of Gelfoam at the enteric opening of the fistula. [45] In this technique, the ECF was assessed by means of computed tomography (CT) and fistulography to rule out any intra-abdominal abscess, distal bowel obstruction, active bowel inflammation, or foreign body that would prevent the fistula from healing. Fistulography also provided information about the fistulous tract and the site of communication with the bowel.

A 5-French introducer sheath was passed along a guide wire into the tract under fluoroscopy and then removed, after which Gelfoam strips or pledgets soaked in contrast material were introduced into the tract through the sheath and pushed down to plug the enteric opening of the ECF. All of the patients healed completely, with no recurrence of ECF over a 2- to 3-year follow-up period.[45]

Postoperative enterocutaneous fistula

Timothy A Pritts, M.D., David R Fischer, M.D., and Josef E Fischer, M.D.

Department of Surgery, University of Cincinnati College of Medicine

Enterocutaneous fistulas may result from a wide variety of conditions and circumstances. Care of these patients can be quite challenging, frustrating, and, ultimately, rewarding. The patient with an enterocutaneous fistula presents the surgeon with a plethora of challenges, and a command of related anatomy, physiology, and metabolism is necessary to successfully meet these challenges.

Postoperative enterocutaneous fistulas, the focus of this brief review, account for approximately 80% of enterocutaneous fistulas. The remainder of enterocutaneous fistulas may occur spontaneously, as a result of tumor, irradiation, or inflammation.

Treatment of patients with postoperative enterocutaneous fistulas requires an understanding of the metabolic and anatomic derangements. In order for mortality of patients with postoperative fistulas to be minimized, nutrition, volume, and electrolyte derangements must be corrected. This must be done in addition to replacing ongoing losses in these areas. Malnutrition is easier to prevent than correct. Once established, malnutrition may be difficult to correct, especially with concomitant sepsis, but malnutrition and sepsis remain principal causes of death in patients with fistulas.

Definition and classification

In its simplest definition, a fistula is a communication between two epithelialized surfaces. Fistulas may be classified based on anatomic, physiologic, or etiologic criteria (table I). Definition of the anatomic course of a fistula is necessary as it may suggest the etiology of the fistula and aid in estimating likelihood of spontaneous closure. Knowledge of fistula anatomy is necessary to plan potential operative strategy towards closure. Physiologic classification of fistulas is based on output (in ml per day). High output fistulas (greater than 500 ml per day) are more likely to originate from the small bowel. Low output fistulas (less than 200 ml per day) are more likely to be colonic in origin. Knowledge of the underlying anatomy and physiology help the physician to anticipate and correct fluid and metabolic derangements. The etiology of the fistula may also aid in predicting spontaneous closure rates and mortality. Fistulas related to malignancy, irradiation, or inflammatory bowel disease are less likely to close spontaneously.

<a href=Table I Classification of fistulas. Post-operative fistulas account for 75–85% of all enterocutaneous fistulas. Although at one time most fistulas were spontaneous, this proportion has been decreasing with improved health care access. Postoperative fistula formation is most common following cancer operations, inflammatory bowel disease operations, or lysis of adhesions. Diagnosis Go to: In the case of enterocutaneous fistulas, the diagnosis is usually obvious, with external drainage of enteric contents. Most postoperative enterocutaneous fistulas are identified in the immediate postoperative period and follow a predictable scenario. The typical patient is 5 or 6 days postoperative, with a fever and persistent ileus. A wound abscess becomes apparent, is drained, and the patient's fever resolves. Within 24 hours, the fistula becomes obvious and enteric contents appear on the wound dressing. Once the diagnosis is made, therapy should be initiated as described below. Treatment Go to: The goals of therapy for patients with enterocutaneous fistulas are to correct metabolic and nutritional deficits, close the fistula, and reestablish continuity of the gastrointestinal tract. The expected treatment course can be divided into five overlapping, but sequential phases ( table II ) . Table II Treatment phases. Phase 1: Recognition and stabilization In this initial period, the presence of an enterocutaneous fistula is established. The patient often has profound metabolic and fluid disturbances. The patient should initially be resuscitated to replace intravascular volume. Anemia, which is often present, should be corrected by transfusion. If the patient is hypoalbuminemic (less than " id="pdf-obj-15-2" src="pdf-obj-15-2.jpg">

Classification of fistulas.

Post-operative fistulas account for 75–85% of all enterocutaneous fistulas. Although at one time most fistulas were spontaneous, this proportion has been decreasing with improved health care access. Postoperative fistula formation is most common following cancer operations, inflammatory bowel disease operations, or lysis of adhesions.

Diagnosis

In the case of enterocutaneous fistulas, the diagnosis is usually obvious, with external drainage of enteric contents. Most postoperative enterocutaneous fistulas are identified in the immediate postoperative period and follow a predictable scenario. The typical patient is 5 or 6 days postoperative, with a fever and persistent ileus. A wound abscess becomes apparent, is drained, and the patient's fever resolves. Within 24 hours, the fistula becomes obvious and enteric contents appear on the wound dressing. Once the diagnosis is made, therapy should be initiated as described below.

Treatment

The goals of therapy for patients with enterocutaneous fistulas are to correct metabolic and nutritional deficits, close the fistula, and reestablish continuity of the gastrointestinal tract. The expected treatment course can be divided into five overlapping, but sequential phases (table II).

<a href=Table I Classification of fistulas. Post-operative fistulas account for 75–85% of all enterocutaneous fistulas. Although at one time most fistulas were spontaneous, this proportion has been decreasing with improved health care access. Postoperative fistula formation is most common following cancer operations, inflammatory bowel disease operations, or lysis of adhesions. Diagnosis Go to: In the case of enterocutaneous fistulas, the diagnosis is usually obvious, with external drainage of enteric contents. Most postoperative enterocutaneous fistulas are identified in the immediate postoperative period and follow a predictable scenario. The typical patient is 5 or 6 days postoperative, with a fever and persistent ileus. A wound abscess becomes apparent, is drained, and the patient's fever resolves. Within 24 hours, the fistula becomes obvious and enteric contents appear on the wound dressing. Once the diagnosis is made, therapy should be initiated as described below. Treatment Go to: The goals of therapy for patients with enterocutaneous fistulas are to correct metabolic and nutritional deficits, close the fistula, and reestablish continuity of the gastrointestinal tract. The expected treatment course can be divided into five overlapping, but sequential phases ( table II ) . Table II Treatment phases. Phase 1: Recognition and stabilization In this initial period, the presence of an enterocutaneous fistula is established. The patient often has profound metabolic and fluid disturbances. The patient should initially be resuscitated to replace intravascular volume. Anemia, which is often present, should be corrected by transfusion. If the patient is hypoalbuminemic (less than " id="pdf-obj-15-26" src="pdf-obj-15-26.jpg">

Treatment phases.

Phase 1: Recognition and stabilization

In this initial period, the presence of an enterocutaneous fistula is established. The patient often has profound metabolic and fluid disturbances. The patient should initially be resuscitated to replace intravascular volume. Anemia, which is often present, should be corrected by transfusion. If the patient is hypoalbuminemic (less than

3 g/dl), consideration should be given to albumin administration, as this may improve bowel function. It is not uncommon for patients to also have intra-abdominal abscesses. Drainage of these abscesses should be carried out only after injection of water-soluble contrast into the abscess by the physician. These studies can yield anatomic information that is otherwise unobtainable. Computed axial tomographic scanning is also useful to evaluate the abdomen for undrained abscesses. As abscess drainage invariably leads to bacteremia, even with antibiotic coverage, central vein catheterization should be delayed until 24 hours after this procedure.

Drainage of the fistula should be controlled. This provides accurate records of daily fistula output, simplifies fluid and electrolyte replacements, and TAP suggest whether or not the fistula is closing spontaneously, and aids wound care. The latter is especially important, as operative closure is much easier with an intact, non-indurated abdominal wall. Simply bagging the fistula can lead to closure of the tract at the skin level while enteric leakage continues, leading to abscess formation. Use of a sump catheter to control drainage is preferred. We have found that the use of a soft latex catheter, such as a Robinson nephrostomy tube, with a 14 gauge intravenous catheter inserted into the tube to serve as an air vent works well.

Care of the skin around the draining fistula is also extremely important. In addition to a mechanism of drainage collection, as described above, the integument also needs to be protected. Several preparations are available the decrease skin maceration and breakdown, including ileostomy cement, Karaya ® powder, Stomadhesive ® , and glycerine. The success of surgical therapy may be improved if excoriation or superinfection of the skin surrounding the fistula tract can be prevented.

After initial stabilization and resuscitation, adequate attention must be directed to nutritional support. Many patients with enterocutaneous fistulas are hypercatabolic and have ongoing nutritional losses. Caloric requirements can be determined from the Harris-Benedict equation, with multiplication by a stress factor, or through indirect calorimetry. Both methods require correction based on patient activity. Nitrogen equilibrium should be achieved in order to restore protein synthesis. Protein requirements range from 1–1.5 grams per kilogram per day for patients with low output fistulas, to as high as 2.5 grams per kilogram per day for some patients with high output fistulas. Fluid requirements can be calculated based on body weight or body surface area and must be adjusted for pre-existing deficits and ongoing fluid losses. With the provision of adequate nutrition to previously malnourished patients, vitamins and trace elements may also be rapidly depleted and patients with high output fistulas should receive almost twice the US recommended daily allowance of water- soluble vitamins. Serum electrolyte levels, including magnesium, should be followed closely and replacements given as needed. Additional zinc supplementation may also be necessary with high output fistulas.

The route of nutrition should be carefully considered. Rates of fistula closure are slightly lower with enteral than with parenteral nutrition, but where possible, the enteral route is preferred, as it carries several real and theoretical advantages over the parenteral route. In general, at least 48 inches of bowel either proximal or distal to the fistula must be present in order to utilize this route. Even if full enteral nutritional support is not practical, a portion of the patient's nutrition should still be given by this route as advantages are probably obtained when as little as 20% of nutritional needs are given enterally. After enteral feeding is initiated, fistula output may transiently increase. If output remains elevated, the tube feeding rate should be decreased and supplemental parenteral nutrition given. In reality, at least a brief overlapping period of both parenteral and enteral nutrition is necessary in most patients as it requires five to ten days to achieve caloric and nitrogen balance by the enteral route.

Recent studies have begun to examine the role of somatostatin in the treatment of fistulas. Treatment with conservative measures alone results in the closure of between 30 and 75% of fistulas, depending on the series and selection criteria. It appears that closure rates with somatostatin treatment are similar, but that the duration of time to closure may be lessened.

Phase 2: Investigation

Following stabilization of the patient and maturation of the fistula tract, the anatomy of the fistula should be investigated radiographically. A fistulogram should be performed as a collaborative effort between the senior surgeon and a senior radiologist. An adequate fistulogram will obviate the need for other gastrointestinal tract examinations, such as a small bowel follow-through or barium enema. Several questions should be answered at this time:

From what region of the bowel does the fistula arise?

2.Is the bowel wall defect larger than 1 cm?

Has the bowel been completely disrupted?

Does the fistula communicate with the bowel distally?

Does the fistula arise from the lateral bowel wall?

Is there an abscess associated with the fistula, and if so, does the fistula drain into the abscess cavity?

Is the adjacent bowel damaged, strictured, or inflamed?

Is there a distal obstruction?

What is the length of the fistula?

The answers to these questions are important, as they assist in identifying fistulas with anatomic features that are less likely to close spontaneously, including those arising from the stomach, ileum, or jejunum at the ligament of Treitz, those with a tract length less than 2 cm in length, with wall defects larger than 1 cm, with complete disruption of the bowel wall, with poor quality of adjacent bowel, or those associated with the presence of a large abscess cavity.

Phase 3: Decision

During this phase, an approach is devised to reach the goal of fistula closure and reestablishment of gastrointestinal continuity. Although spontaneous closure is the ideal outcome, this may occur in only about one third of patients with complicated fistulas. In addition to the anatomic characteristics discussed above, unfavorable factors related to fistula closure include poor nutritional status, presence of sepsis, active Crohn's disease, active malignancy, presence of a foreign body, epithelialization of the fistula tract, and a serum transferrin less than 200 milligrams per deciliter. The expected time period for spontaneous closure, if it is to occur at all, varies with the anatomic location of the fistula. Fistulas from the esophagus and duodenum are expected to heal in two to four weeks. Colonic fistulas may heal in 30 to 40 days. Small bowel fistulas may take at least 40 to 60 days.

If uncontrolled sepsis is present at any point, urgent abscess drainage or resection of a phlegmon should be carried out, preferably with restoration of intestinal continuity at that time. Likewise, patients with solid organ transplants should also have relatively brief periods of non-operative management due to immunosuppression and impaired wound healing. Otherwise, a period of nutritional support and trial of spontaneous closure may allow the patient's abdominal skin to heal as well as improve the patient's nutritional status and overall condition prior to operation.

Phase 4: Definitive therapy

If the anatomic features of the fistula preclude spontaneous closure or an anatomically favorable fistula has not closed in the expected time frame (4–5 weeks of sepsis free adequate parenteral nutrition), the patient should be prepared for operative closure. Ideally, with meticulous skin care and control of fistula drainage, the abdominal wall will be healthy, enhancing the opportunity for secure abdominal closure. The patient is prepared for operation in the standard fashion, with intraluminal antibiotics and mechanical bowel preparation. Discontinuation of enteral nutrition prior to operation may decrease abdominal distension and aid in abdominal closure.

Entering the abdomen through a new incision is preferred if possible. Dissection to free the bowel from the ligament of Treitz to the rectum is then carried out. The bowel should be freed from all adhesions to ensure that there is no obstruction. This usually requires extensive dissection, meticulous technique, and, not infrequently, a great deal of time. The highest closure and lowest complication rates may be obtained by resection of the involved section of bowel with end-to-end anastomosis. Other procedures should be performed only if this is not possible. Enteral access for the postoperative period should be established, either through a gastrostomy, which can also be used for gastric decompression, a feeding jejunostomy, or preferably both.

One circumstance in which resection and end-to-end anastomosis should not be performed is the patient with a duodenal fistula. Satisfactory closure of these fistulas can be achieved with a bypass procedure, such as gastrojejunuostomy.

At the end of the operation, secure abdominal wall closure should be obtained. If the abdominal wall has been compromised, such as with partial destruction by sepsis, a plastic surgeon should be consulted to assist closure, and flaps may be necessary.

Phase 5: Healing

In the postoperative period, it is necessary to ensure that the patient continues to receive full nutritional support. Adequate protein and calories must be provided to maximize healing and minimize complications. Although enteral nutrition may be attempted early in the post-operative course, it is nearly impossible to meet the patient's entire nutritional demand by this route. Thus, postoperative care will most likely include parenteral and enteral supplementation in an overlapping manner.

After fistula closure, whether by spontaneous or surgical means, the patient will need to resume oral intake. This my be especially difficult in an individual who has had little or no oral intake for 4 to 6 weeks or more, and enlisting the assistance of a dietician and the patient's family is often helpful. Weaning enteral and parenteral nutritional supplementation and switching to nocturnal tube feeds may help to increase appetite.