Transcript IN THE NAME OF GOD

IN THE NAME OF GOD
1
ENTERIC FISTULAS
ENTERIC FISTULAS
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 represent a second group of complex intraperitoneal infectious
processes.
 Mortality remains high, between l0-30% in recent series.
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largely due to the frequent complications of sepsis and malnutrition.
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Electrolyte imbalances, as a third key factor leading to mortality
CLASSIFICATION
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 Classified by:
 the anatomy of the stnrctures involved
 the amount and composition of drainage
 the etiology responsible for their formation
 In addition to classification,these distinctions may provide important
prognostic information about the physiologic impact of fistulas and
the likelihood that they will close without surgical resection,the
principal decision confronting the responsible surgeon.
ETIOLOGIC CLASSIFICATION
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 Enterocutaneous fistulas result from several processes:
 (1) diseased bowel extending to surrounding structures
 (2) extraintestinal disease involving otherwise normal bowel
 (3) trauma to normal bowel including inadvertent or missed
enterotomies
 (4) anastomotic disruption following surgery for a variety of conditions
 Fistulas between the alimentary tract and skin may be classified as
postoperative or spontaneous.
ETIOLOGIC CLASSIFICATION
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 Approximately three-quarters of fistulas occur following:
 an operation,most commonly subsequent to procedures performed for
malignancy, inflammatory bowel disease, or adhesions
ETIOLOGIC CLASSIFICATION
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 Patient factors that increase the likelihood of developing a
postoperative fistula include:
 Malnutrition
 Infection
 emergency operations with concomitant hypotension, anemia,
hypothermia,and poor oxygen delivery
ETIOLOGIC CLASSIFICATION
7
 If possible, these conditions should be corrected prior to operation,
but in emergency situations, optimization of resuscitation and
performance of a technically meticulous procedure including adequate
mobilization, good quality bowel with good blood supply, and no
tension will provide the best chance of a good outcome.
ETIOLOGIC CLASSIFICATION
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 Postoperative enterocutaneous fistulas result from:
 either disruption of the anastomosis
 inadvertent (and often unrecognized) bowel injury during the
dissection or abdominal closure
 Attention to avoidance of tension or ischemia in the creation of
anastomoses is paramount in minimizing postoperative
enterocutaneous fistulas.
 The remaining 25 percent of fistulas do not occur following a surgical
procedure.
spontaneous fistulas
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 spontaneous fistulas often develop in:
 patients with cancer
 Following radiation therapy
 Fistulas occurring in the setting of malignancy or Irradiation are
unlikely to close without operative intervention.
 Inflammatory conditions such as:
 inflammatory bowel disease
 diverticular disease
 perforated ulcer disease
 Ischemic bowel
spontaneous fistulas
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 Of these, fistulas in patients with inflammatory bowel disease are most
common; these fistulas often close following a prolonged period of
parenteral nutrition, only to reopen when enteral nutrition resumes.
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An understanding of the etiology of an enterocutaneous fistula may
provide information about the ultimate need for surgical intervention.
ANATOMIC CLASSIFICATION
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 Fistulas may communicate with
 the skin (external fistulas)
 or other intraperitoneal
 or intrathoracic organs (internal fistulas)
ANATOMIC CLASSIFICATION
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 Internal fistulas that bypass only short segments of bowel may not be
symptomatic; however,internal fistulas of bowel that bypass significant
length of bowel or that communicate with either the bladder or vagina
typically cause symptoms and become clinically evident.
 However,internal fistulas of bowel that bypass significant length of
bowel or that communicate with either the bladder or vagina typically
cause symptoms and become clinically evident. The identification and
management of internal fistulas is beyond the scope of this
ANATOMIC CLASSIFICATION
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 internal fistulas should be resected if :
 they are symptomatic
 cause physiologic or metabolic complications
Small bowel fistulas
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 .The majority of gastrointestinal cutaneous fistulas arise from the small
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intestine.
Seventy to ninety percent of enterocutaneous fistulas occur in the
postoperative period.
postoperative small bowel fistulas result from either disruption of
anastomoses or injury to the bowel during dissection or closure of the
abdomen.
Operations for cancer
in flammatory bowel disease, and adhesiolysis are the most common
procedures antecedent to small bowel fistula formation.
Small bowel fistulas
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• During the course of a procedure, resection with end-to-end
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anastomosis is recommended for small bowel defects and injuries,
especially when simple closure would be expected to reduce the luminal
diameter.
All sersosal injuries should be repaired with intermpted 3-0 silk
sutures.
Spontaneous small bowel fistulas arise from inflammatory bowel
disease, cancer, peptic ulcer disease, or pancreatitis.
Crohn's disease is the most common cause of spontaneous small bowel
fistula.
The transmural inflammation underlying Crohn's disease may lead to
adhesion of the small bowel to the abdominal wall or other abdominal
structures.
Small bowel fistulas
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Microperforation may then cause absces formation and erosion into
adjacent structures or the skin.
 Roughly half of Crohn's fistulas are internal and half are external.
 crohn's fistulas tpyically follow one of two courses:

 The first type represents fistulas that present in the early postop_
erative period following resection of a segment of diseased bowel.
 These fistulas arise in otherwise healthy bowel and follow a course
similar to non-Crohn's fistulas with a significant likelihood of sponta_
 neous closure.
 The other group of Crohn's fistulas arises in diseased bowel and has a
low rate of spontaneous closure.
Small bowel fistulas
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 Additionally, should spontaneous closure occur, these fistulas often
reopen upon resumption of enteral intake.
 Early operative closure of these fistulas should be considered.
Colonic fistulas
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 Spontaneous fistulas of the colon result from diverticulitis, malignancy,
inflammatory bowel disease, appendicitis, and pancreatitis, while
treatment of these conditions accounts for the majority of postoperative
colocutaneous fistulas.

Anastomotic breakdown or extension from inadequately resected
disease bowel account for the majoriry of the postoperative fistulas.
 Additionally,with gastrocutaneous fistulas, an increased incidence of
colocutaneous fistulas has been reported following percutaneous
gastrostomy placement.
Colonic fistulas
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 Appendiceal fistulas may result from drainage of an appendiceal
abscess or appendectomy in a patient with Crohn's disease.
 the fistula often originates from the terminal ileum, not the cecum.
 The inflamed ileum adheres to the abdominal wall closure and sub_
 sequently results in fistula formation.
 Erosion of a percutaneous drain for spontaneous right lower quadrant
abscess is also an increasing cause of gastrointestinal cutaneous fistula
in Crohn's disease.
 Radiation therapy contributes to both spontaneous and postoperative
colocutaneous fistulas.
Colonic fistulas
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Techniques to provide additional protection and blood supply to
anastomoses performed under these conditions include coverage of
anastomoses with omentum, filling of dead space with muscle flaps, or
sigmoid exclusion.
 proximal diverting colostomy or ileostomy may allow sufficient
anastomotic healing prior to sutureline challenge with luminal
contents.
 Operation or reoperation in an irradiated field is subject to recurrence
of colocutaneous fistulas, and these fistulas are unlikely to undergo
spontaneous closure.
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Fistula tract characteristic
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 addition to describing the organs involved in fistulas, anatomic
characteristics of fistula tracts may also be helpful in determining
prognosis (Table 7-2).

Due to anatomic considerations and the nature of effluent from
different sites in the enteric tract, certain locations are more likely to
undergo spontaneous closure.
 These favorable types include oropharyngeal, esophageal, duodenal
stump, and jejunal fistulas.
 Unfavorable sites include the stomach, lateral duodenum, ligament of
Treitz,and ileum.
Fistula tract characteristic
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Fistula tract characteristic
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 Anatomic factors suggesting low likelihood of spontaneous closure
include fistulas associated with large abscesses, intestinal wall defects
of greater than 1 cm, intestinal discontinuity, distal obstruction,
diseased adjacent bowel, and fistulous tracts of less than 2 cm (Fig 7-5).
 In contrast, fistulas with intestinal wall defects less than 1 cm and
longer tracts are more likely to undergo spontaneous closure.
Fistula tract characteristic
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Physiological classification
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Enterocutaneous fistulas cause the loss of fluid, minerals,trace
elements, and protein, as well as allow the release of irritating and
caustic substances onto the skin and subcutaneous tissues.
 Accurate measurement of both the amount and nature of enteroCutan_
eous effluent allows for accurate replacement and an understanding
of the physiologic and metabolic challenges to the patient (Table 7-3).
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Fistulas may be divided into high-output (>500 mL per day),
moderate-output (200-500 mL/day), and low-output (<200 mL/day)
groups.
Physiological classification
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Physiological classification
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 Classification of enterocutaneous fistulas by the amount of daily output
provides information regarding mortality, and in recent series may
predict spontaneous closure.
 the classic series of Edmunds and associates, patients with high-output
fistulas had a mortality rate of 54%, compared to a l6% mortality rate in
the low-output group.
 More recently,Lervy and colleagues reported a 50% mortality rate in
patients with high-output fistulas, while those with low-output fistulas
had a 26% mortality.
Physiological classification
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•
In the largest series reported to date, Soeters and coworkers reported
no association between fistula output and rate of spontaneous closure,
while multivatiate analysis by Campos and associates suggested that
patients with low-output fistulas were three times more likely to
achieve closure without operative intervention.
 The reason for these different rates of closure is that high-output
fistulas are likely to be of small-bowel origin,while low-output fistulas
are likely to be of colonicorigin.
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Moderate-volume fistulas tend to be of either colonic or mixed smalland large-bowel origin (seeTable 7-2).
Prevention
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 Proper preoperative patient preparation and meticulous surgical
technique will lessen the risk of postoperative fistula formation.
 In the elective setting, operation may be delayed to allow for normali_
zaion of nutritional parameters, thus optimizing wound healing and
immune function.
• Several nutritional characteristics have been suggested to increase the
risk of anastomotic breakdown:
1. Weight loss of 10-15% of total body weight over 3-4 months
2. Serum albumin less than 3 mg/dL
3. Serum transferrin less than 220 mg/dL
4. Anergy to recall antigens
5. Inability to perform activities of daily living due to weakness or
fatigue.
Prevention
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 Mechanical and antibiotic bowel preparation reduce the amount of
particulate fecal material as well as colonic bacterial counts. In practice,
mechanical bowel preparation for elective colon operations combined
with systemic antibiotics with activity against enteric organisms
provides adequate prophylaxis.
Prevention
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 In emergency operations, delays for optimization of nutritional status
and bowel preparation are not possible.
 Instead, emphasis should be on adequate resuscitation and restoration
of circulating volume, normalization of hemodynamics, provision of
appropriate antibiotic therapy,and meticulous surgical technique
 Performance of anastomoses in a healthy, well-perfused bowel without
tension provides the best chance for healing, especially when one can
easily see the performance of the anastomosis clearly.
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Careful hemostasis to avoid postoperative hematoma formation will
decrease the risk of abscess
Prevention
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 while inadvertent enterotomies and serosal injuries should be
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identified and repaired. If possible, an omental flap should be used to
separate the anastomosis from the abdominal incision.
Secure abdominal wall closure using healthy tissue and care to avoid
injury to the underlying bowel are important to prevent postoperative
fistula formation.
In the postoperative period, further resuscitation may be required to
ensure hemodynamic stability and avoid inadequate tissue
oxygenation.
It is essential to avoid periods of transient postoperative hypotension
related to the anesthesia.
Diagnosis,Evaluation and Manegment
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 Regardless of the etiology or specific nature of the fistula,the ultimate
goals in treating patients with enterocutaneous fistula are the reestablishment of bowel continuity,the ability to achieve oral nutrition,
and the closure of the fistula.
•
Given the metabolic and septic physiology often present with entero_
cutaneous fistulas, recognition of the development of an enterocu_
taneous fistula should prompt aggressive resuscitation and stabilization
of the patient.
Diagnosis,Evaluation and Manegment
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•
Drainage of obvious septic sources must be undertaken and nutritional
support commenced
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Nutritional support should be delayed 24 hours for drainage, as
hematogenous seeding of the catheter may result in catheter sepsis.
•
If an abscess is pointing, one should do a fistulogram through the
abscessb efore open drainage, using an angiocath to see where the
water-soluble dye tracks to.
Diagnosis,Evaluation and Manegment
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•
This information in combination with the patient's response to
nonoperative measures determines the length of time before operative
intervention is performed.
•
If surgery is required, meticulous technique in combination with a wellprepared team approach will optimize the likelihood of a successful
patient outcome.
Operative closure of the fistula does not end the surgical team's
obligation to the patient, as continued nutritional support and physical
and emotional rehabilitation are often required to return the patient to
his or her pre-illness state.
As in any complicated illness, care of the patient with an enterocutan_
eous fistula can be divided into several phases (Table 7-4).
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Diagnosis,Evaluation and Manegment
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Phase1:Recognition and Stabilization
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the patient presenting with a postoperative enterocutaneous fistula
may do well initially for the first few days after operation.
 Within the first week, however, the patient may suffer delayed return of
bowel function and fever.
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Erythema of the wound develops and opening the wound reveals
purulent drainage that is soon followed by enteric contents.
•
The diagnosis is now clear and management shifts from routine
postoperative care to the management of a potentially critically ill
patient.
Phase1:Recognition and Stabilization
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•
The combined insults of the preoperative disease process,a bowel
preparation, a week of minimal nutritional support, and a septic state
often results in a profoundly volume-depleted patient.
•
The first stage in management of the fistula patient, therefore, is the
restoration of volume using crystalloid and colloid products as
appropriate to restore oxygen-carrying capacity and plasma oncotic
pressure.
•
Several liters of crystalloid are usually required to replace fluid lost
into the bowel and bowel wall.
Phase1:Recognition and Stabilization
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 while maintenance of a specific target hematocrit is controversial,
blood should be transfused to support oxygen-carrying capacity to a
hematocrit of at least 30%.
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Similarly, albumin may aid in wound healing and intestinal functionoa
and is involved in the transport of certain nutrients and medications
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Administration of albumin to a serum level of 3.0 mg/dL supports
these functions.
Phase1:Recognition and Stabilization
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The leakage of enteric contents outside of the bowel lumen may lead to
generalized peritonitis or abscess in addition to fistula formation.
 As the leading cause of mortality in modern series of enterocutaneous
fistula, aggressive management of sepsis is essential in these patients.
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 Frankly septic patients should be explored to drain abscesses.
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ursing these procedures, consideration should be given to performing
a fistulogram by injecting water-soluble contrast into the abscess under
fluoroscopic guidance.
Phase1:Recognition and Stabilization
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 Percutaneous drainage of collections in nonseptic patients should also
be performed.
 Placement of central venous catheters for parenteral nutrition should
be delayed for 24 hours following drainage of septic foci, as bacteremia
following these procedures may seed catheters, leading to line sepsis.
 The use of antibiotics in patients with enterocutaneous fistulas should
be reserved for specific indications.
 Most large series of patients with fistulas demonstrate that patients
received seven to nine antibiotics during their treatment.
 in order to avoid selecting for resistant organisms, antibiotics should
only be given for defined infections and for a set duration of therapy.
Phase1:Recognition and Stabilization
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 Concorent with drainage of sepsis, a plan to control fistula drainage
and provide local skin care will prevent continued irritation of the
surrounding skin and abdominal wall structures.
 Very-low-output fistulas may appear to be adequately managed with
dry dressings;however should the skin close over the fistula tract.
 In this experience, a sump constructed from a soft latex catheter (i.e.,
Robinson nephrostomy tube) may be placed in the wound (Fig 7-6).
Phase1:Recognition and Stabilization
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Phase1:Recognition and Stabilization
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 This tube is soft at body temperature and will not erode into the bowel
or abdominal wall structures.
 Accurate recording of fistula output is facilitated by this drainage
system.
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More recendy, vacuum assisted closure (VAC) devices have been
reported to both aid in the care of these complicated wounds and
promote nonoperative closure( Fig 7-7).
Phase1:Recognition and Stabilization
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Phase1:Recognition and Stabilization
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 while there are no large series or randomized trials of the use of these
devices in the management of enterocutaneous fistula, VAC dressings
provide another option for wound care in these patients.
 The disadvantage of VAC dressings is the amount of time necessary to
change these dressings, often 2-2.5 hours.
 However, these dressings need only bechanged every 5 or so days.
Phase1:Recognition and Stabilization
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 while fistula output does not correlate with the rate of spontaneous
closure, reduction of fistula drainage may facilitate wound manage_
ment and decrease the time to closure.
 In the absence of obstruction, prolonged nasogastric drainage is not
indicated and may even contribute to morbidity in the form of patient
discomfort, impaired pulmonary toilet,alar necrosis, sinusitis or otitis
media, and late esophageal stricture.
 Measures to decrease the volume of enteric secretions include admini_
stration of histamine antagonists or proton pump inhibitors.
Phase1:Recognition and Stabilization
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 Reduction in acid secretion will also aid in the prevention of gastric and
duodenal ulceration as well as decrease the stimulation of pancreatic
secretion.
 Sucralfate, a mucosal protective agent, may also reduce gastric acidity
while also providing a constipating action that may decrease fistula
output as well As inhibitors of the secretion of many gastrointestinal
hormones inclu_ ding gastrin, cholecystokinin, secretin,insulin,
glucagons, and vasoactive peptide.
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it has been hoped that somatostatin and octreotide may reduce time to
closure and promote nonoperative closure of enterocutaneous fistulas.
Phase1:Recognition and Stabilization
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 Somatostatin and its analogue octreotide may be used to reduce
gastrointestinal secretions, fistula output, and time to closure;
 however, data that demonstrate an effect on the rate of nonoperative
closure of enterocutaneous fistulas are lacking.
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potential side effects of the use of these agents include difficult glucose
homeostasis and cholelithiasis.
 Large prospective, randomized trials are needed to further clarify the
role of somatostatin and octreotide in the management of enterocu_
taneous fistulas.
 Octreotide may accelerate closure of pancreatic fistulas.
Phase1:Recognition and Stabilization
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 however Infliximab, a monoclonal antibody to tumor necrosis factor-
alpha, has been shown to be beneficial in inflammatory and fistulizing
inflammatory bowel disease.
 Use of infliximab in patiens with fistulas following ileal pouch-anal
anastomosis for ulcerative colitis resulted in clinical response in six of
seven patients and fistula closure in five patients after three treatments.
 In a study of 100 patients with fistulizing Crohn's disease, infliximab
infusion resulted in complete response in 50 patiens,partial response
in 22 patients, and no response in 28 patients.
Phase1:Recognition and Stabilization
53
 In a randomized trial of patients with chronic fistulas (duration greater
than 3 months), administration of infliximab resulted in a significantly
increased rate of closure of all fistulas when compared to placebo.
 Adverse events in these trials were largely infectious complications,
including abscess formation, pneumonia,varicella zoster, Candidn
esophagitis, and upper respiratory tract infection.
 Evidence suggests a role of infliximab in treatment of fistulas compli_
cating inflammatory bowel disease; whether this agent will be of use in
patiens without Crohn's disease or ulcerative colitis remains to be
determined.
Phase1:Recognition and Stabilization
54
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Provision of nutritional support may be all that is necessary for spont_
aneous healing of enterocutaneous fistulas.
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Alternatively, should operative intervention be required, normalization
of nutritional parameters will provide the patient with the best chance
for successful fistula resolution.
 Malnutrition,identified by Edmunds in 1960 as a major contributor to
mortality in these patients, may be present in 55-90% of patients with
enterocutaneous fistulas.
Phase1:Recognition and Stabilization
55
 Patients with postoperative enterocutaneous fistulas are often mal_
nourished due to a combination of poor enteral intake, the hypercat_
abolic septic state, and the loss of protein-rich enteral contents through
the fistula.
 Proper nutrition may improve immune function, provide protein
precursors for wound healing, and sup port the functions of the gastro_
intestinal tract.
Phase1:Recognition and Stabilization
56
 As a general guideline, we provide 25-32kilocalories per kilogram per
day with a calorie:nitrogen ratio of 150:1 to 100:1 and at least 1.5 grams
per kilogram per day of protein. These are general principles of
nutritional management and ongoing reassessment of each patient's
clinical and laboratory values are required to optimize support for these
complex patients.
 Parenteral nutrition has long been the corner_stone of support for
patients with enterocutaneous fistu1as.
.
Phase1:Recognition and Stabilization
57
•
Transition to partial or total enteral nutrition has been advocated in
recent reports to prevent atrophy of gastrointestinal mucosa as well as
support the immunologic and hormonal functions of the gut and liver.
•
Additionally, parenteral nutrition is expensive and requires dedicated
nursing care to prevent undue morbidity and mortality from line
insertion,catheter sepsis, and metabolic complications
Phase1:Recognition and Stabilization
58
•
Enteral feeding may occur per os, via feeding tubes placed nasogas_
trically or nasoenterically, or via the fistula itself (i.e., fistuloclysis).
 Enteral support typically requires 4 feet of small intestine and is
contraindicated in the presence of distal obstruction.
•
Drainage from the fistula may be expected to increase with the
commencement of enteral feeding; however, spontaneous closure may
still occur, often preceded by a decrease in fistula output.
Phase1:Recognition and Stabilization
59
 Eleven of twelve patients were able to discontinue parenteral support
and nutritional status was maintained until surgery in nine patients
(19_422days) and for at least 9 months in the two patients who did not
undergo operative intervention.
 Of note, surgeons in this study also reported improved bowel caliber,
thickness, and ability to hold sutures in patients who had received
enteral nutrition
Phase2:Investigation
60
 Once the patient has been stabilized with control of sepsis and comme-
ncement of nutritional support, investigation into the course and
character of the fistula should be undertaken.
 This typically occurs 7-10 days after the identification of the fistula and
allows time for the fistula tract to mature to the point where catheters
can be placed in all orifices.
 Careful fistulography with water-soluble contrast provides information
not obtainable through any other means.
 The senior surgeon responsible for the patient's care should be present
with the most-senior available radiologist for the performance of the
study.
Phase2:Investigation
61
 Particular attention should be paid to the length, course, and relation_
ships of the fistula tract, the absence or presence of bowel continuity or
distal obstruction, the nature of the bowel adjacent to the fistula, and
the absence or presence of an abscess cavity in communication with
the fistula (see Fig 7-5).
Phase2:Investigation
62
Phase2:Investigation
63
 These details will help determine whether surgical intervention will be
necessary as well as aid in the planning of such a procedure.
 The early films, without a lot of dye, give the most information.
 Computed tomography is most useful in the early management of
patients with fistulas to identify abscesses and guide percutaneous
interventions.
Fistula tracts are not usually visible on axial CT imaging, although
sagittal or reconstructed images may provide useful information.
 Barium contrast upper gastrointestinal studies and enemas rarely
provide additional information.

Phase3:Decision
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 Ideally, provision of a period of sepsis-free nutrition will result in
closure of enterocutaneous fistulas within 4-6 weeks.
 Spontaneous closure of fistulas restores intestinal continuity and
allows resumption of oral nutrition.
 Unfortunately, complex fistulas undergo spontaneous closure in only
one-third of cases. Therefore, once resuscitation,wound care, and
nutritional support are assured, a decision must be made regarding the
likelihood of spontaneous closure of a specific fistula.
 Information obtained from imaging investigations provides anatomic
details about the fistula, while the specifics of the clinical course of the
patient, including weight gain, improvement in nutritional parameters,
and decrease in fistula output provide prognostic details.
Phase3:Decision
65
 Fistulograms demonstrating fistulas arising from diseased bowel, in
proximity to large abscesses,in settings of disruption of intestinal
continuity, in the presence of distal obstruction, and those with short
tracts (less than 2 cm) are unlikely to close without operative
intervention.
Similarly, fistulas originating in the stomach, ileum, or near the
ligament of Tieitz have lower rates of spontaneous closure.
 In contrast,fistulas arising from biliary, pancreatic, or jejunal
sources are more likely to resolve spontaneously (seeTable 7-2).
 Fistulas associated with inflammarory bowel disease often close with
nonoperative management only to reopen upon resumption of enteral
nutrition.
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Fistula tract characteristic
66
Phase3:Decision
67
 These fistulas should be formally resected once closed to prevent
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recurrence.
Fistulas in the setting of malignancy or irradiated bowel are particularly
resistant to closure and would suggest the need for earlier operative in_
tervention.
The timing of operative intervention for fistulas that are unlikely to or
fail to close is important.
Early operation is indicated to control sepsis not amenable to
percutaneous intervention.
These early procedures are typically limited to drainage of abscess and
resection of phlegmona with definitive resection of fistulas deferred
until the patient can be nutritionally and physiologically optimized.
Phase3:Decision
68
 The common practice of waiting at least 4-6 weeks for definitive
operative management of enterocutaneous fistulas is based on several
factors.
 First,90-95% of fistulas that will spontaneous close typically do so
within 5 weeks of the original operatisn.
 Furthermore, operation during the first 10 days to 6 weeks from
diagnosis of postoperative fistulas is made more difficult by the
"obliterative peritonitis" described by Fazio and associates.
 In this series, reoperations within 10 days of or delayed at least 6 weeks
from the original procedure resulted in mortality rates of l3%
and 11%, respectively.
Phase3:Decision
69
 In contrast, patients undergoing reoperations between l0 days and 6
weeks of the original laparotomy suffered a mortality rate of 26%.
 Additionally, delaying operative intervention allows for nutritional
support and normalization of serum albumin and transferrin, while
delay also allows resolution of local abdominal wound sepsis and
preparation of the abdominal wall for secure closure.

Optimally, if operation is required, 4 months should elapse from the
last operative procedure because the adhesions will have matured and
will be easier to deal with after that interval.
Phase4:definitive manegment
70
 Just as the initial management and diagnosis of patients with
gastrointestinal cutaneous fistulas is time- and labor intensive, the
definitive operative reconstruction of these complicated patients
requires the commitment of significant time and resources.
 The surgical team should expect to be in the operating room for up to 7
or 8 hours.
 Should a complex abdominal wall closure be expected, a fresh team of
plastic and reconstructive surgeons should be involved in the planning
and performance of the procedure and should be consulted Pre_
operatively with enough time to plan the reconstructive procedure.
 The patient should have achieved optimal nutritional parameters and
be free of all signs of sepsis.
Phase4:definitive manegment
71
 Through careful management of fistula drainage, a well-healed
abdominal wall without inflammation should be present.
 Prophylactic antibiotics should be administered based on the patient's
previous microbiological data, and tube feedings should be tapered in
the days preceding operation to allow mechanical and antibiotic
preparation of the bowel.
 The operation should commence through a new incision distant from
any potential sources of inflammation or infection.

Often, a transverse incision offers the best opportunity to enter the
abdomen in an area free of adhesions.
Phase4:definitive manegment
72
 If the prior midline incision musr be used,entering the abdomen either
above or below the limits of the previous incision reduces the risk of
inadvertent entry into adherent bowel.
 Wound towels dipped in antibiotic solution or wound protectors should
be used to prevent contamination of the abdominal wall tissues during
the course o[the operation.
 Dissection to free the entire length of the bowel from the ligament of
Theiz to the rectum is termed bowel refunctionalization.
 Refunctionalization identifies and allows resection of all areas of
abscess and all sources of obstruction, thus ensuring the best possible
chance of avoiding failure of the present operation.
 Dissection commences in the areas of least dense adhesions.
Phase4:definitive manegment
73
 Use of antibiotic-soaked laparotomy pads on areas of dense adhesions
often creates edema that aids in further dissection.
 Use of the scalpel and scissors to sharply dissect adhesions prevents
inadvertent damage to the bowel, as does approaching adhesions from
the side, rather than head-on.

Careful attention to dissection and closure of all enterotomies in the
manner of Heineke-Mikulicz and serosal tears with Lembert sutures of
5_0 Prolene provides the patient with the best possible outcome.
 Resection of the bowel involved in the fistula is preferred over bypass,
Roux-en-Y drainage, or simple serosal patching, although these
approaches may be necessary in extreme cases.
Phase4:definitive manegment
74
 Bowel anastomosis should be performed using a two_layer,
interrupted, end-to-end anastomosis with nonabsorbable sutures in
healthy bowel.
 Avoiding tension and ensuring adequate blood supply are principles of
sound surgical practice that must be followed in these difficult
reoperative cases.
 Both throughout and following the steps of dissection,resection, and
anastomosis, frequent irrigation of the abdominal cavity with antibiotic
solution should be performed,and constant vigilance for inadvertent
bowel injrry should be maintained.
Phase4:definitive manegment
75

For duodenal fistulas,however, if operation is required, a direct attack
on the fistula is less wise.

Instead a gastrojejunostomy, with or without vagotomy, with
gastrostomy, jejunostomy, and drainage is most likely to give a
successful result.
 Placement of a flap of omentum between the fresh anastomosis and the
abdominal wall closure may prevent recurrence of fistulization.

Use of Seprafilm may be an adjuvant therapy to aid in prevention of
complications from future adhesions.
Phase4:definitive manegment
76
 Consideration of Placement of a decompressive gastrostomy using a no




20 whistle-tip catheter obviates the need for prolonged postoperative
nasogastric tube placement in the event of prolonged ileus, which may
be expected.
Nasogastric tubes are uncomfortable and may interfere with
ambulation and pulmonary toilet.
Similarly,placement of a feeding jejunostomy may also aid in the
postoperative care of patients undergoing procedures of this scale.
Abdominal wall closure is the final operative step in the management of
patients with enterocutaneous fistulas and is of utmost importance in
preventing recurrence.
If the abdominal wall has recovered from the previous inflammation
and sepsis, a primary closure may be possible.
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77
 f a difficult closure is anticipated, a complex myocutaneous flap
procedure may be required.The involvement of the plastic and recons_
tructive surgical service is advised under these circumstances and the
use of a fresh team will maximize the likelihood of a good outcome for
the patient.

Under no circumstances should mesh or Goretex be used for closure;
intact native tissue should be at the bowel-peritoneal interface or
refistulization will likely occur.
 As the cumulative experience with complex laparoscopic procedures
has increased, several groups have reported laparoscopic approaches to
enteric and enterocutaneous fistulas.
Phase4:definitive manegment
78
 The largest of these series reported 73 procedures in 72 patients, 20%of
which were enterocutaneous fistulas.
 The authors reported a mean operative time of 199 minutes with a
4.1% conversion rate.
 A verage postoperative length of stay was 5.2 days with a complication
rate of 11%, consisting of postoperative bleeding, readmission for artial
small bowel obstruction and cholecystitis, and infectious complications
including pneumonia, urinary tract infection,central line sepsis, and
wound infection.
 In this series. there was one recurrence of a diverticular colovesical
fistula 5 months postoPeratively.
Phase4:definitive manegment
79
 the role of laparoscopy in managing enterocutaneous fistula patients
will likely continue to evolve, the complex nature of many of these
fistulas will demand an open approach in order to ensure the best
outcome for the patient.
Phase 5:healing
80
 Whether closure of fistulas occurs spontaneously or through operative




management, contimration of support is necessary to avoid recurrence.
Nutritional support via tube feedings should be continued until the
patient is consistently tolerating at least 1500 kilocalories per day
orally.
Healing of the surgical wound and anastomoses requires a positive
nitrogen balance to avoid breakdown of newly formed proteins.
Oral feeding typically commences 1 week postoperatively with a soft
diet, rather than with the traditional progression from clear liquids
to full liquids.
The patient's family and nutritional support staff will play an
important role in providing foods that are appealing to the patient, as it
is often difficult to persuade these patients to eat.
Phase 5:healing
81
 Zinc supplementation may improve patients' sense of taste and increase
oral intake.
 Similarly, cycling tube feedings overnight may stimulate hunger and
increase food intake during the day.
 Delayed complications continue to be a risk for fistula patients even
after healing of their fistulas.

Postoperative complications such as anastomotic stricture and
adhesive small bowel obstruction, as well as short-bowel
syndrome due to multiple resections and recurrence of Fistuli_
zation may all impede patient recovery.
Phase 5:healing
82
 While reoperation in these patients remains a challenge, standard
surgical principles should be followed in decision making and
performance of any further procedures.
 By the time their fistulas have closed, enrerocuraneous fistula patients
have often been hospitalized for several months with limited
ambulation and have suffered from septic and metabolic challenges,
thus leaving them physically deconditioned and emotionally fatigued.

Physical and occupational therapists play a role throughout each
patient's hospitalization, but their efforts become even more important
during the healing phase as the focus shifts to reintroducing the patient
to normal activities of daily living.
Phase 5:healing
83
 Involvement of case management staff early in the patient's course will
identify obstacles to the patient's successful reintroduction to an active
lifestyle,while use of psychiatric consultation-liaison services will
identify and address issues of depression and adaptive disorders.
 Finally, active involvement by the senior surgeon responsible for the
patient's care to ensure a coherent treatrnent plan and adequate
communication with the patient and family will help avoid confusion
and fear while dealing with these challenging cases.
 One complication not widely reported is the inability of these patients
to think clearly and have appropriate decision making.
Phase 5:healing
84
 This is particularly important for business owners and highly-placed
executives.
 This is likely due to protein depletion in the brain. This complication
normally takes 12-18 months to resolve.
 The patient should be reassured that this complication will resolve
spontaneously with good nutrition
conclusion
85
 Gastrointestinal cutaneous fistulas remain dreaded complications of
cancer, inflammatory bowel disease,and general surgical operations.
 An understanding of the pathophysiology and risk factors for
developmenr of these fistulas may minimize their creation as well as
provide a sound plan for their management.
Early recognition and resuscitation of patients with fistulas combined
with control of sepsis and provision of nutritional support may limit
associated complications.
 Investigation into the anatomic and etiological characteristics of each
fistula may provide information about the likelihood of spontaneous
closure or suggest earlier operative management.

conclusion
86
 Careful planning and technique during definitive surgical therapy and
the involvement of a multidisciplinary team will provide the best
possibility of resolurion of the fistula.
 Finally, postoperative maintenance of adequate nutrition and physical
and emotional support may allow restoration of the patient to a
functional and productive role in society and ensures the durability of
the repair.
87