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NCBI » Bookshelf » Surgical Treatment » Small Bowel » Postoperative enterocutaneous fistula

surg
Surgical Treatment
Evidence-Based and Problem-Oriented
HolzheimerRené G
MannickJohn A
1
Martin-Luther University Halle-Wittenberg, Wallbergstraße 15a, D-82054 Sauerlach, Germany
2
Department of Surgery, Brigham and Womens Hospital, Harvard University Medical School, 75 Francis Street, Boston
MA 02115, USA
W. Zuckschwerdt Verlag3-88603-714-22001
© 2001 W. Zuckschwerdt Verlag GmbH
surgery
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
Introduction
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
Classification of fistulas
Table I
Classification of fistulas
Category Type of fistula Uses of information
Anatomy Internal vs. external May suggest cause of fistula
Anatomic course Assists in planning operative closure
May predict spontaneous closure
Physiology Output (ml per day) Predicts mortality
Low (< 200) Predicts metabolic derangements
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Fistula desde el Diagnostico al tratamiento
Category Type of fistula Uses of information
Moderate (200–500)
High (> 500)
Etiology By underlying disease process Predicts closure rate
Predicts mortality
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.
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
Treatment phases
Table II
Treatment phases
Phase Time Course Primary goals
1. Recognition and Correct fluid and electrolyte
24–48 hours
stabilization imbalances
Drainage of intra-abdominal abscesses
Control of sepsis
Control of fistula drainage
Ensure adequate skin care
Aggressive nutritional support
Determine anatomy and fistula
2. Investigation after 7–10 days
characteristics
Determine likelihood of spontaneous
3. Decision up to 4–6 weeks
closure
Plan course of therapy
after 4–6 weeks or if closure is
4. Definitive therapy Closure of fistula
unlikely
Reestablish gastrointestinal continuity
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Phase Time Course Primary goals
Secure closure of abdomen
5. Healing 5–10 days after closure onward Ensure adequate nutritional support
Transition to oral intake
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).
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
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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:
1.- From what region of the bowel does the fistula arise?
2.- Is the bowel wall defect larger than 1 cm?
3.- Has the bowel been completely disrupted?

4.-Does the fistula communicate with the bowel distally?

5.- Does the fistula arise from the lateral bowel wall?
6.- Is there an abscess associated with the fistula, and if so, does the fistula drain into the
abscess cavity?
7.- Is the adjacent bowel damaged, strictured, or inflamed?
8.- Is there a distal obstruction?9.- 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

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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.
References
1.
Dudrick S J, Maharaj A R, McKelvey A A. Artificial nutritional support in patients with
gastrointestinal fistulas. World J Surg. (1999); 23: 570–576. [PubMed]
2.
Berry S M, Fischer J E. Classification and management of enterocutaneous fistulas. Surg Clin
North Am. (1996); 76: 1009–1018. [PubMed]
3.
Martineau P, Shwed J A, Denis R. Is octreotide a new hope for enterocutaneous and external
pancreatic fistulas closure? Am J Surg. (1996); 172: 386–395. [PubMed]
4.
Paran H, Neufeld D, Kaplan O, Klausner J, Freund U. Octreotide for treatment of postoperative
alimentary tract fistulas. World J Surg. (1995); 19: 430–433. [PubMed]
5.
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Berry S M, Fischer J E. Enterocutaneous fistulas. Curr Prob Surg. (1994); 31: 469–566.
6.
Kuvshinoff B W, Brodish R J, McFadden D W, Fischer J E. Serum transferrin as a prognostic
indicator of spontaneous closure and mortality in gastrointestinal cutaneous fistulas. Ann Surg.
(1993); 217: 615–623. [PubMed] [ Free Full text in PMC]
Copyright © 2001 W. Zuckschwerdt Verlag GmbH
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