Postoperative Enterocutaneous Fistula: When to Reoperate and How to Succeed

 

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ABSTRACT

An enterocutaneous fistula (ECF) is a potentially catastrophic postoperative complication. Although the morbidity and mortality associated with ECF have decreased over the past 50 years with modern medical and surgical care, the overall mortality is still surprisingly high, up to 39% in recent literature. It seems prudent, then, for every surgeon to have a thorough grasp of optimal treatment strategies for ECF to minimize their patients' mortality. Ultimately, the algorithm must begin with prevention. Once an ECF is diagnosed, the first step is to resuscitate and treat sepsis. The second is to control fistula output. The third step is to optimize the patient medically and nutritionally. The last step is definitive restoration of gastrointestinal continuity when necessary. Special mention is given in this article to exceptionally refractory fistulas such as those arising in the presence of inflammatory bowel disease and irradiated bowel. This plan gives a framework for the difficult task of successfully treating the postoperative ECF with a multidisciplinary approach.

REFERENCES

• 1 Cameron J. Current Surgical Therapy. 7th ed. St. Louis, MO; Mosby 2001: 156-161
  Google Scholar
• 2 Haffejee A A. Surgical management of high output enterocutaneous fistulae: a 24-year experience.  Curr Opin Clin Nutr Metab Care. 2004;  7 309-316
  PubMedGoogle Scholar
• 3 Alvarez C, McFadden D W, Reber H A. Complicated enterocutaneous fistulas: failure of octreotide to improve healing.  World J Surg. 2000;  24 533-538
  CrossrefPubMedGoogle Scholar
• 4 Makhdoom Z A, Komar M J, Still C D. Nutrition and enterocutaneous fistulas.  J Clin Gastroenterol. 2000;  31 195-204
  CrossrefPubMedGoogle Scholar
• 5 Campos A C, Andrade D F, Campos G M, Matias J E, Coelho J C. A multivariate model to determine prognostic factors in gastrointestinal fistulas.  J Am Coll Surg. 1999;  188 483-490
  CrossrefPubMedGoogle Scholar
• 6 Memon A S, Siddiqui F G. Causes and management of postoperative enterocutaneous fistulas.  J Coll Physicians Surg Pak. 2004;  14 25-28
  PubMedGoogle Scholar
• 7 Berry S M, Fischer J E. Classification and pathophysiology of enterocutaneous fistulas.  Surg Clin North Am. 1996;  76 1009-1018
  CrossrefPubMedGoogle Scholar
• 8 Sinha S K, Sethy P K, Kaman L et al.. Multiple spontaneous enterocutaneous fistulae in malakoplakia.  Indian J Gastroenterol. 2003;  22 234-235
  PubMedGoogle Scholar
• 9 Evenson A R, Fischer J E. Current management of enterocutaneous fistula.  J Gastrointest Surg. 2006;  10 455-464
  CrossrefPubMedGoogle Scholar
• 10 Lynch A C, Delaney C P, Senagore A J, Connor J T, Remzi F H, Fazio V W. Clinical outcome and factors predictive of recurrence after enterocutaneous fistula surgery.  Ann Surg. 2004;  240 825-831
  CrossrefPubMedGoogle Scholar
• 11 Chambers W M, Mortensen N J. Postoperative leakage and abscess formation after colorectal surgery.  Best Pract Res Clin Gastroenterol. 2004;  18 865-880
  CrossrefPubMedGoogle Scholar
• 12 D'Harcour J B, Boverie J H, Dondelinger R F. Percutaneous management of enterocutaneous fistulas.  AJR Am J Roentgenol. 1996;  167 33-38
  PubMedGoogle Scholar
• 13 Kaur N, Minocha V R, Mundu M. Improving outcome in patients of high output small bowel fistula.  Trop Gastroenterol. 2004;  25 92-95
  PubMedGoogle Scholar
• 14 Kaushal M, Carlson G L. Management of enterocutaneous fistulas.  Clin Colon Rectal Surg. 2004;  17 79-88
  Article in Thieme ConnectPubMedGoogle Scholar
• 15 Goverman J, Yelon J A, Platz J J, Singson R C, Turcinovic M. The “fistula VAC” a technique for management of enterocutaneous fistulae arising within the open abdomen: report of 5 cases.  J Trauma. 2006;  60 428-431
  CrossrefPubMedGoogle Scholar
• 16 Nienhuijs S W, Manupassa R, Strobbe L J, Rosman C. Can topical negative pressure be used to control complex enterocutaneous fistulae?.  J Wound Care. 2003;  12 343-345
  PubMedGoogle Scholar
• 17 Cro C, George K J, Donnelly J, Irwin S T, Gardiner K R. Vacuum assisted closure system in the management of enterocutaneous fistulae.  Postgrad Med J. 2002;  78 364-365
  CrossrefPubMedGoogle Scholar
• 18 Medeiros A C, Aires-Neto T, Marchini J S, Brandao-Neto J, Valenca D M, Egito E S. Treatment of postoperative enterocutaneous fistulas by high-pressure vacuum with a normal oral diet.  Dig Surg. 2004;  21 401-405
  CrossrefPubMedGoogle Scholar
• 19 Wang X B, Ren J A, Li J S. Sequential changes of body composition in patients with enterocutaneous fistula during the 10 days after admission.  World J Gastroenterol. 2002;  8 1149-1152
  PubMedGoogle Scholar
• 20 Evans J P, Steinhart A H, Cohen Z, McLeod R S. Home total parenteral nutrition: an alternative to early surgery for complicated inflammatory bowel disease.  J Gastrointest Surg. 2003;  7 562-566
  CrossrefPubMedGoogle Scholar
• 21 Lloyd D A, Powell-Tuck J. Artificial nutrition: principles and practice of enteral feeding.  Clin Colon Rectal Surg. 2004;  17 107-118
  Article in Thieme ConnectPubMedGoogle Scholar
• 22 Teubner A, Morrison K, Ravishankar H R, Anderson I D, Scott N A, Carlson G L. Fistuloclysis can successfully replace parenteral feeding in the nutritional support of patients with enterocutaneous fistula.  Br J Surg. 2004;  91 625-631
  CrossrefPubMedGoogle Scholar
• 23 Mettu S R. Correspondence: fistuloclysis can successfully replace parenteral feeding in the nutritional support of patients with enterocutaneous fistula (Br J Surg 2004;91:625-631).  Br J Surg. 2004;  91 1203
  PubMedGoogle Scholar
• 24 Arebi M, Forbes A. High-output fistula.  Clin Colon Rectal Surg. 2004;  17 89-98
  Article in Thieme ConnectPubMedGoogle Scholar
• 25 Jamil M, Ahmed U, Sobia H. Role of somatostatin analogues in the management of enterocutaneous fistulae.  J Coll Physicians Surg Pak. 2004;  14 237-240
  PubMedGoogle Scholar
• 26 Torres A J, Landa J I, Moreno-Azcoita M et al.. Somatostatin in the management of gastrointestinal fistulas. A multicenter trial.  Arch Surg. 1992;  127 97-99
  CrossrefPubMedGoogle Scholar
• 27 Hesse U, Ysebaert D, Hemptinne B. Role of somatostatin-14 and its analogues in the management of gastrointestinal fistulae: clinical data.  Gut. 2001;  49(Suppl IV) iv11-iv20
  CrossrefPubMedGoogle Scholar
• 28 González-Pinto I, González E M. Optimising the treatment of upper gastrointestinal fistulae.  Gut. 2001;  49(Suppl IV) iv22-iv31
  PubMedGoogle Scholar
• 29 Maconi G, Parente F, Porro G B. Hydrogen peroxide enhanced ultrasound- fistulography in the assessment of enterocutaneous fistulas complicating Crohn's disease.  Gut. 1999;  45 874-878
  CrossrefPubMedGoogle Scholar
• 30 Regueiro M. The role of endoscopy in the evaluation of fistulizing Crohn's disease.  Gastrointest Endosc Clin N Am. 2002;  12 621-633
  CrossrefPubMedGoogle Scholar
• 31 Eleftheriadis E, Kotzampassi K. Therapeutic fistuloscopy: an alternative approach in the management of postoperative fistulas.  Dig Surg. 2002;  19 230-236
  CrossrefPubMedGoogle Scholar
• 32 Rabago L R, Ventosa N, Castro J L, Marco J, Herrera N, Gea F. Endoscopic treatment of postoperative fistulas resistant to conservative management using biological fibrin glue.  Endoscopy. 2002;  34 632-638
  Article in Thieme ConnectPubMedGoogle Scholar
• 33 Dalton D, Woods S. Successful endoscopic treatment of enterocutaneous fistulas by histoacryl glue.  Aust NZ J Surg. 2000;  70 749-750
  CrossrefPubMedGoogle Scholar
• 34 Johnson E K, Gaw J U, Armstrong D N. Efficacy of anal fistula plug vs. fibrin glue in closure of anorectal fistulas.  Dis Colon Rectum. 2006;  49 371-376
  CrossrefPubMedGoogle Scholar
• 35 Schultz D J, Brasel K J, Spinelli K S, Rasmussen J, Weigelt J A. Porcine small intestine submucosa as a treatment for enterocutaneous fistulas.  J Am Coll Surg. 2002;  194 541-543
  CrossrefPubMedGoogle Scholar
• 36 Hollington P, Mawdsley J, Lim W, Gabe S M, Forbes A, Windsor A J. An 11-year experience of enterocutaneous fistula.  Br J Surg. 2004;  91 1646-1651
  CrossrefPubMedGoogle Scholar
• 37 Zografos G C, Peros G, Androulakis G. Palliative surgical treatment in enterocutaneous fistula.  J Surg Oncol. 1997;  66 138
  CrossrefPubMedGoogle Scholar
• 38 Poritz L S, Gagliano G A, McLeod R S, MacRae H, Cohen Z. Surgical management of entero and colocutaneous fistulae in Crohn's disease: 17 year's experience.  Int J Colorectal Dis. 2004;  19 481-485
  PubMedGoogle Scholar
• 39 Present D H, Rutgeerts P, Targan S et al.. Infliximab for the treatment of fistulas in patients with Crohn's disease.  N Engl J Med. 1999;  340 1398-1405
  CrossrefPubMedGoogle Scholar
• 40 Sands B E, Anderson F H, Bernstein C N et al.. Infliximab maintenance therapy for fistulizing Crohn's disease.  N Engl J Med. 2004;  350 876-885
  CrossrefPubMedGoogle Scholar
• 41 Poritz L S, Rowe W A, Koltun W A. Remicade does not abolish the need for surgery in fistulizing Crohn's disease.  Dis Colon Rectum. 2002;  45 771-775
  CrossrefPubMedGoogle Scholar
• 42 Date R S, Panesar K J, Neilly P. Infliximab as a therapy for non-Crohn's enterocutaneous fistulae.  Int J Colorectal Dis. 2004;  19 603-606
  CrossrefPubMedGoogle Scholar
• 43 Chamberlain R S, Kaufman H L, Danforth D N. Enterocutaneous fistula in cancer patients: etiology, management, outcome, and impact on further treatment.  Am Surg. 1998;  64 1204-1211
  PubMedGoogle Scholar
• 44 Chintamani , Badran R, Rk D, Singhal V, Bhatnagar D. Spontaneous enterocutaneous fistula 27 years following radiotherapy in a patient of carcinoma penis.  World J Surg Oncol. 2003;  1 23
  CrossrefPubMedGoogle Scholar
• 45 Regimbeau J M, Panis Y, Gouzi J L, Fagniez P L. French University Association for Surgical Research . Operative and long term results after surgery for chronic radiation enteritis.  Am J Surg. 2001;  182 237-242
  CrossrefPubMedGoogle Scholar
• 46 Russell J C, Welch J P. Operative management of radiation injuries of the intestinal tract.  Am J Surg. 1979;  137 433-442
  CrossrefPubMedGoogle Scholar
• 47 Lui R C, Friedman R, Fleischer A. Management of postirradiation recurrent enterocutaneous fistula by muscle flaps.  Am Surg. 1989;  55 403-407
  PubMedGoogle Scholar

Kathryn L GalieM.D. 

West County Surgical Specialists, Inc.

621 South New Ballas Rd., Ste. 7011B, St. Louis, MO 63141

Email: klgalie@yahoo.com