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Review on enterocutaneous fistula

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Presentation on theme: "Review on enterocutaneous fistula"— Presentation transcript:

1 Review on enterocutaneous fistula

2 Definition Enterocutaneous fistula Fistula output
Abnormal pathological connection between skin and GI tract Fistula output High output > 500ml / 24 hr Non high output Moderate output: ml / 24 hr Low output: <200 ml / 24 hr Current Management of Enterocutaneous Fistula Journal of Gastrointestinal Surgery 2006;10:455–464

3 Causes Post abdominal surgery Malignancy Infection / inflammation
Leading cause, 75-85% Malignancy Infection / inflammation IBD, diverticulitis, appendicitis, PPU, etc Radiation Abdominal trauma Congenital

4 Prognosis Mortality Spontaneous fistula closure
Overall mortality 10-20% Mortality up to 30-35% for high output fistula Spontaneous fistula closure ~30%, range from 20-80% 80-90% closure within 6 weeks

5 Mortality sepsis Fluid and electrolyte disturbance malnutrition

6 Prognostic factors on fistula closure rate
favorable unfavorable anatomical Esophageal, duodenal stump, pancreatobiliary, jejunal, colon Tract > 2cm Defect < 1cm Gastric, lateral duodenal, ileal Distal obstruction Complex fistula / associated abscess Epithelialization of tract etiological Post-operative Diverticulitis / appendicitis Malignancy IBD Foreign body Radiation general Malnutrition Sepsis Steroid / chemotherapy Co-morbidities Reference: Nutrition and Enterocutaneous Fistulas Journal of Clinical Gastroenterology 2000;31(3):195–204

7 Management approach for ECF
SNAP S: stabilization, sepsis control, skin care N: nutrition support A: assessment of anatomy P: plan of definitive treatment / surgery Management of Complex Gastrointestinal Fistula Current Problems in Surgery 2009; 46:

8 Stabilization Fluid and electrolyte correction Sepsis control

9 Fluid and electrolyte Aggressive monitoring and replacement of fluid, electrolytes and acid-base Control of fistula output Modification of enteral intake NPO Restriction of hypo-osmolar fluid intake / intake of fluid rich in sodium / glucose Low residual diet / elemental diet Pharmacotherapy Anti-motility agents PPI Somatostatin / analogue

10 Somatostatin and its analogue
Review on randomized controlled trial on effect of somatostatin / octreotide on fistula healing Nutrition and management of enterocutaneous fistula British Journal of Surgery 2006;93:1045–1055

11 Somatostatin and its analogue
Time to closure Somatostatin may shorten time to closure Octreotide result inconsistent Fistula closure rate Most studies show no significant improvement in fistula healing rate with somatostatin / octreotide

12 Sepsis control Source of sepsis Assessment Drainage of collection
Intra-abdominal collection Others: catheter related infection, skin infection, chest infection, UTI Assessment CT scan Drainage of collection Image guided percutaneous drainage Surgical drainage +/- proximal diversion

13 Skin care Various barrier device / skin protectants
Suction drainage of fistula VAC system for open wound There were a few case series in which VAC was used in managing ECF with open wound successfully (Cro and colleagues, Gunn and colleague)

14 Skin care Current Management of Enterocutaneous Fistula
Journal of Gastrointestinal Surgery 2006;10:455–464

15 Nutrition Nutrition and Enterocutaneous Fistulas
Journal of Clinical Gastroenterology 2000;31(3):195–204

16 TPN Important in management of ECF
Indicated when enteral feeding not feasible or inadequate

17 Enteral feeding vs bowel rest
No randomized trials investigating outcomes in patients with early enteral feeding vs complete bowel rest have been performed Experience from studies with aggressive approach to early enteral nutrition show similar outcome in terms of mortality and fistula closure rate compared to other studies with more parenteral nutrition

18 Enteral feeding Preferred if feasible after initial stabilization
Improve mucosal integrity Avoid complication of TPN Access Oral Feeding tube / stoma distal to fistula Fistuloclysis: tube feeding via fistula to distal limb of GI tract

19 Assessment of anatomy Site of origin of fistula
Anatomy of fistula tract Complexity Length of tract Defect size Status of distant bowel Integrity obstruction

20 Assessment of anatomy CT scan Fistulogram Other GI contrast study MRI
Intra-abdominal collection Underlying causes Fistulogram Anatomy of fistula tract and GI tract Other GI contrast study MRI Endoscopy

21 Definitive plan of management
Conservative Surgery Novel treatment

22 Spontaneous closure unlikely..
FRIEND Foreign body Radiation injury Inflammatory bowel disease Epithelialization of fistula tract Neoplasm Distal obstruction

23 Surgical intervention
Indications Conservative management fails Sepsis cannot be controlled Timing of surgery Preferably 3-6 months after presentation / previous operation unless life-threatening sepsis Patient well optimized and disease well assessed

24 Surgical intervention
Surgical approach Incision and access Adequate mobilization / assessment of bowel Resection vs repair Diversion: stoma / bypass Abdominal wall closure

25 Surgical intervention
Resection of diseased bowel with primary anastomosis more preferable than repair of defect if possible Lower risk of recurrence as demonstrated in a retrospective study from Cleveland (Annals of Surgery, Volume 240, Number 5, November 2004) General rate of recurrence after surgery ranged from 10-35%

26 Novel treatment Fibrin glue Gelfoam embolization
A non randomized study from Mexico study on the use of fibrin glue on patients with low output fistula and showed shorter healing time compared to control group (World Journal of Gastroenterology, 2010 June 14; 16 (22): 2793 – 2800) Gelfoam embolization Fluoroscopic guided placement of catheter at the enteric opening of the fistula and gelfoam was injected to occlude the fistula at its enteric opening A case series from Australia (Lisle and colleagues) reported successful use of gelfoam embolization in treating 3 patients with low output fistula (Disease of the Colon and Rectum 2006; 50: 251–256)

27 Summary of management approach for ECF

28 END

29 Fistuloclysis A case series was reported in UK (Teubner and colleagues), in which fistuloclysis was attempted in 12 patients with small bowel fistulas, 11 out of the 12 patients were able to wean off TPN Fistuloclysis can successfully replace parenteral feeding in the nutritional support of patients with enterocutaneous fistula British Journal of Surgery 2004;91:625–631

30 Gelfoam embolization Percutaneous Gelfoam Embolization of Chronic Enterocutaneous Fistulas: Report of Three Cases Disease of the Colon and Rectum 2006; 50: 251–256

31 Resection vs repair

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