1. Entero-cutaneous Fistulas- An evidence based approach to management
Pearl quartey
University of Washington
pgy1

2. Case: JJ
14 yo male
HPI: re-admitted with wound infection, leukocytosis. Found to have enterocutaneous fistula on wound exploration.
PMH
Crohn’s disease due to IL-10 receptor deficiency
History of stem cell transplant with unmatched donor at age 11
PSH
8 months
History of severe strictures with resultant ileostomy at age 3
Multiple dilations for perianal strictures
Few orthopedic surgeries
Ileostomy take down with sigmoid loop colostomy 7/11/14
Wound I&D 7/25

3. Background: ECF/EAF
Typically complex patients with significant morbidity and mortality
Mortality rates have dropped significantly since 1960s (65% to less than 10%) 2
Most commonly occur in small bowel – 50%
70-80% of fistulas will respond to conservative management and close in about 6-8 weeks
Entero-atmospheric fistulas (EAF): communication between loops of bowel or other hollow viscus and the atmosphere i.e. open abdomen or chest. Exposed hole in bowel lumen without overlying skin or tissue
Trauma surgery night mare
Do not close without surgical intervention, mortality remains high (10-15%)1
Deep or superficial
Significant cost to healthcare systems: extended hospital admissions, multiple surgeries, multi-disciplinary teams
Significant psychosocial costs to patients and families
Dubose JJ, Lundy JB. Enterocutaneous fistulas in the setting of trauma and critical illness. Clinics in Colon and Rectal Surgery 2010;23(3):182–9
Martinez JL, Luque-de-Leon E, Mier J, Blanco-Benavides R, Robledo F. Systematic management of postoperative enterocutaneous fistulas: factors related to outcomes. World Journal of Surgery 2008;32(3):436–43.

4. Common causes of fistula formation
Spontaneous formation (15-25%)
Malignant disease
Radiation therapy
Inflammatory conditions
Inflammatory bowel disease (20% Crohn’s disease)
Bowel obstruction or ischemia
Complicated diverticular disease or appendicitis
Perforated ulcer disease
Infectious diseases: tuberculosis & actinomycosis
Lundy JB, Fischer JE (2010) Historical perspectives in the care of patients with enterocutaneous fistula. Clin Colon Rectal Surg 23:133–141

5. Common causes (cont’d)
Postoperative/iatrogenic (75-85%)
Oncologic procedures
Bowel resection
Colostomy or ileostomy takedown
Emergent laparotomy/ trauma
Appendectomy
Adhesiolysis
Lundy JB, Fischer JE (2010) Historical perspectives in the care of patients with enterocutaneous fistula. Clin Colon Rectal Surg 23:133–141

6. Ileostomy with associated fistula
Courtesy of the Enterostomal Nursing Department, Cleveland Clinic, Cleveland, OH

7. Classification- several systems
Physiologic: based on daily output. Debate about potential for spontaneous closure based on volume of output.
Low < 200mL/d: colonic, may tolerate PO intake
Medium mL/day
High > 500mL/day
Anatomic location
Simple or complex: based on number of fistula tracts
Internal vs external
Etiology: e.g. malignant, diverticular etc.

8. Traditional approach to management
Sepsis control: most significant determinant of outcome
Identification and treatment of source
Empiric antibiotics, antifungals,
Stabilization
Fluid resuscitation
Electrolyte abnormalities
Nutritional support
Enteral vs. parental feeding
Effluent management
PPIs, anti-motility agents, somatostatin analogues
Wound care
Definitive repair
Surgical
Reconstruction

9. Requires multi-disciplinary team- creation of centers of excellence1
Enterostomal therapists
Surgeons- general, plastics
Nurses
Radiologists
Nutritionists
Infectious disease specialists
Psychiatrists/psychologists
1. Jamie Murphy, Alexander Hotouras, Lena Koers, Chetan Bhan, Michael Glynn, Christopher L. Chan, Establishing a regional enterocutaneous fistula service: The Royal London hospital experience, International Journal of Surgery, Volume 11, Issue 9, 2013, Pages ,

10. Sepsis control Abscess vs peritonitis Antibiotics
CT guided drainage of intra-abdominal abscesses
IR placement of drains: avoid early surgery
Exlap for peritonitis

11. Nutrition- preventing the catabolic state
Positive nitrogen balance
High daily caloric requirements especially protein
Aggressive fluid & eletrolyte replacement
Early TPN:
Early enteral feeding
Fistuloclysis: enteral feeds through the fistula
Indicators of worse survival:
Albumin < 2.5g/dL carries 42% mortality vs albumin > 3.5 0% mortality1
Pre-albumin
Transferrin level
1. V.W. Fazio, T. Coutsoftides, E. Steiger. Factors influencing the outcome of treatment of small bowel cutaneous fistula World J Surg, 7 (1983), pp. 481–488

12. Enteral feeding
Early enteral feeding has become standard of care for critically ill patients 1,2
No level 1 evidence for its use in ECF patients
Various studies have reported improved fistula closure outcomes with enteral feeding either PO or via fistuloclysis. Usually requires 60-70cm of bowel
Common barriers:
Intestinal discontinuity
Inadequate bowel length
Inability to maintain adequate enteral feeding access
Dramatic increases in fistula output leading to further skin breakdown
Yuan Y, Ren J, Gu G, Chen J, Li J. Early enteral nutrition improves outcomes of open abdomen in gastrointestinal fistula patients complicated with severe sepsis. Nutrition in Clinical Practice 011;26(6):688–94
McClave SA, Martindale RG, Vanek VW (2009) Guidelines for the provision of nutrition support therapy in the adult critically ill patient: Society for Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N). JPEN J Parenter Enteral Nutr 33:277–316

13. Fistuloclysis- enteral feeding through fistula
No randomized trials
Anecdoctal and isolated case reports
Careful patient selection

14. An 18 French MIC transgastric jejunal feeding tube (Kimberly-Clark Health Care) inserted in the lumen of the distal fistula.
An 18 French MIC transgastric jejunal feeding tube (Kimberly-Clark Health Care) inserted in the lumen of the distal fistula.
Wright S J et al. JPEN J Parenter Enteral Nutr 2012;37:
Copyright © by The American Society for Parenteral and Enteral Nutrition

15. Stoma appliance linked to the universal access port.
Stoma appliance linked to the universal access port. Proximal fistula output evident.
Wright S J et al. JPEN J Parenter Enteral Nutr 2012;37:
Copyright © by The American Society for Parenteral and Enteral Nutrition

16. Effluent management Proton pump inhibitors
Anti-motility agents- loperamide
Somatostatin and analogues: (octreotide & lanreotide) . Very Few RCTs- 8. Meta-analysis and systematic reviews1,2,3
Decreased time to closure
No difference in mortality
Rahbour G, Siddiqui MR, Ullah MR, Gabe SM, Warusavitarne J, Vaizey CJ. A meta-analysis of outcomes following use of somatostatin and its analogues for the management of enterocutaneous fistulas. Annals of Surgery 2012;256(6):946–54.
Stevens P, Foulkes R, Hartford-Beynon J, Delicata RJ. Systematic review and meta-analysis of the role of somatostatin analogues in the treatment of non-pancreatic enterocutaneous fistulae. European Journal of Gastroenterology and Hepatology 2011;23(10):912–22
Koti RS, Gurusamy KS, Fusai G, Davidson BR. Metaanalysis of randomized controlled trials on the effectiveness of somatostatin analogues for pancreatic surgery: a Cochrane Review. HPB (Oxford) 2010;12:155–65

17. Wound care Large ostomy appliances used historically
Skin graft: reduces fluid losses and bacterial colonization
VAC system3: reduces wound edema, removes purulent material, encourages angiogenesis
Significant cost however less than prolonged hospital stay. Managed well in the community
2Concern about contact with bowel and formation of more fistulas when used with wounds that contain fistulas
1Small study showed shorter closure times in patients with no visible mucosa
L.A. Gunn, K.E. Follmar, M.S. Wong, S.C. Lettieri, L.S. Levin, D. Erdmann Management of enterocutaneous fistulas using negative-pressure dressings Ann Plast Surg, 57 (2006), pp. 621–625.2.
2. J.E. Fischer. A cautionary note: the use of vacuum-assisted closure systems in the treatment of gastrointestinal cutaneous fistula may be associated with higher mortality from subsequent fistula development Am J Surg, 196 (2008), pp. 1–2
J. Goverman, J.A. Yelon, J.J. Platz, R.C. Singson, M. Turcinovic. The “Fistula VAC,” a technique for management of enterocutaneous fistulae arising within the open abdomen: report of 5 cases. J Trauma, 60 (2006), pp. 428–431 discussion 431

18. Definitive repair
Consensus is to delay surgery for a minimum of 6 months after the initial surgery 1. Reasons are:
Clear infection
Improve nutritional status
Well controlled wound
Intra-abdominal adhesions can lead to difficult dissection and multiple enterotomies with ensuing fistulas
Reasons for earlier surgical intervention:
Source control
Proximal stoma creation
Intolerable wound management
1. Martinez JL, Luque-de-León E, Ballinas-Oseguera G, Mendez JD, Juárez-Oropeza MA, Román-Ramos R. Factors predictive of recurrence and mortality after surgical repair of enterocutaneous fistula. Journal of Gastrointestal Surgery 2012;16(1):156–63

19. reconstruction Tissue flaps Muscle flaps Mesh and other synthetics
Porcine materials

20. Other points to consider
1Laparoscopic surgery: requires high level of expertise in laparoscopic colorectal surgery, high risk of missed enterotomies
2Percutanous gelfoam embolization: CT scan, fistulogram, embolization under fluoroscopic guidance
3Metal clips: idea derived from using clips for closing perforations during colonoscopies. Limited use in very few patients
Transplant for intestinal failure
Anti-TNF therapy in Crohn’s patients
N. Pokala, C.P. Delaney, K.M. Brady, A.J. Senagore. Elective laparoscopic surgery for benign internal enteric fistulas: a review of 43 cases Surg Endosc, 19 (2005), pp. 222–225
D.A. Lisle, J.C. Hunter, C.W. Pollard, R.C. Borrowdale. Percutaneous gelfoam embolization of chronic enterocutaneous fistulas: report of three cases. Dis Colon Rectum, 50 (2007), pp. 251–256
R. Kumar, S. Naik, N. Tiwari, S. Sharma, S. Varsheney, H.S. Pruthi Endoscopic closure of fecal colo-cutaneous fistula by using metal clips Surg Laparosc Endosc Percutan Tech, 17 (2007), pp. 447–451

21. Stoma through midline incision due to tension
Courtesy of the Enterostomal Nursing Department, Cleveland Clinic, Cleveland, OH

22. summary
75% of fistulas are iatrogenic. Prevention is key to managing fistulas
Patient selection, basic surgical practices key to preventing fistula formation
Use of minimally invasive procedures in high risk patients can help with reducing the risk of fistulization
Interventional radiology embolizing mesenteric arteries in GI bleed, placing drains in intra-abdominal abscesses
Key is to wait for several months before re-operation if possible.

23. Future directions Enteral vs parental feeding?
RCT for somatostatin analogues