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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
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.
Table I
Classification of fistulas.
Post-operative fistulas account for 7585% 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
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).
Table II
Treatment phases.
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