Management Of Enterocutaneous Fistulas Research Articles

The gastrointestinal breach: understanding enterocutaneous fistula

The term "fistula" usually refers to abnormal communication between two epithelial surfaces and an enterocutaneous fistula (ECF) is an abnormal communication between any part of gastrointestinal (GI) tract and skin and lined by epithelium or granulation tissue. Common causes include trauma during abdominal surgery, inflammatory bowel disease, malignancy, infection, radiation etc. Sepsis and malnutrition are the leading causes of mortality. In cases of high-output fistula, it is essential to adequately replace the excessive fistula discharge. The patient's nutrition plays a crucial role in the successful management of ECFs. If the patient can tolerate oral or enteral feeding, it should be initiated promptly. However, if oral intake is not feasible, parenteral nutrition should be considered. Adequate wound care, including diligent skincare and timely drainage of localized abscesses, is necessary. Before conducting definitive investigations and initiating treatment, it is important to ensure proper resuscitation and stabilization of the patients. Surgical intervention should be approached in staged manner and should not be rushed to prevent failure in managing this complex condition. To conclude management of ECF is complicated and needs multidisciplinary approach. Initial focus for remedy is on treating fluid and electrolyte disturbances, comprehensive treatment of sepsis, management of fistula output, skin care and psychological support.

Medical and surgical management of enterocutaneous fistula

Development of enterocutaneous fistula (ECF) remains a challenging complication of gastrointestinal surgery and fistulizing disease processes. Successful management of ECF is dependent on timely diagnosis, effective treatment of resulting intra-abdominal sepsis, wound/nutrition management, and supporting the patient though the perioperative optimization period. When approached in multi-disciplinary setting with teams specializing in ECF/intestinal failure, care is optimized and can allow for patients to have greater independence even with complex wounds. While resolution of the ECF remains the overarching goal, a methodical and stepwise approach to management remains paramount both before and after surgical intervention. This chapter outlines ECF management from initial diagnosis to intra-operative decision making after a patient is deemed a candidate for surgery. Further, it highlights patient-specific considerations that can be overlooked in the big picture view of ECF management. While ECF treatment is challenging, the chance to cure a patient of their fistula is a rewarding experience for the patient and ECF/intestinal failure team members alike.

Use of oral diet and nutrition support in management of stricturing and fistulizing Crohn's disease.

Crohn's disease (CD), a form of inflammatory bowel disease, involves chronic inflammation within the gastrointestinal tract. Intestinal strictures and fistulas are common complications of CD with varying severity in their presentations. Modifications in oral diet or use of exclusive enteral nutrition (EEN) are common approaches to manage both stricturing and fistulizing disease, although supporting research evidence is generally limited. In the preoperative period, there is strong evidence that EEN can reduce surgical complications. Parenteral nutrition (PN) is often utilized in the management of enterocutaneous fistulas, given that oral diet and EEN may potentially increase output in proximal fistulas. This narrative review highlights the current practices and evidence for the roles of oral diet, EEN, and PN in treatment and management of stricturing and fistulizing CD.

A prospective study on enterocutaneous fistula in a tertiary care centre: A single institution study

Background: Aberrant connection linking gastrointestinal tract and the skin is termed Enterocutaneous fistula. Enterocutaneous fistulas can lead to significant morbidity and mortality. Death pertaining to enterocutaneous fistulas remains enormous when juxtaposed with other surgeries. The treatment of Enterocutaneous fistula may be a significant challenge to surgeons and gastroenterologists. Method: After obtaining ethical committee clearance, a total of 25 patients of Enterocutaneous fistula who presented to Surgical department and Surgical Gastroenterology department were included in the study. The cause, site and output of fistula, clinical course and complications of fistula were studied. Patients were managed either surgically or conservatively depending on the output of the fistula, nutrition and metabolic profile. Results: 19 patients were managed conservatively and 6 patients were managed surgically. Amidst the conservative group, 16 out of 19 patients had spontaneous closure of fistula and remaining three had died as fistulas failed to close. Surgical closure was accomplished in 5 patients but failed in one patient and that patient died. 96% (24 out of 25) of patients in our study had developed fistula post operatively. Among 25 patients studied, nearly 44% each i.e., 11 out of 25 patients had colonic and small bowel fistula respectively followed by fistula at appendix accounting for 12% (i.e., Fistula Output: 11 (44%) fistulae were low output, 8 (32%) were medium output. Conclusion: Enterocutaneous fistulas are more common in postoperative period. Conservative treatment should be the mainstay in management of Enterocutaneous fistula.

Management of Enterocutaneous Fistula with VAC therapy. Case report and literature review

Enterocutaneous fistulas are a rare complication of the usual abdominal-intestinal surgical practice that represent a challenge for the surgeon in his treatment that is generally stagnant due to the progressive deterioration of the condition of the patient suffering from the fistula. There are multiple treatment modalities and accepted schemes. In recent years, VAC therapy has gained ground in this pathology,We presenting the case of a 60-year-old man who presented enterocutaneous fistula after ileostomy closure as a postoperative complication, which is managed with therapy. VAC.

Management of Enterocutaneous Fistula: A Review.

Enterocutaneous fistula is any communication between bowel and skin or atmosphere outside the body. It can be classified by various means by etiology, organ of origin, etc. Enterocutaneous fistula can occur after any gastrointestinal surgery where there is some trauma during surgery or other associated causes such as malignancy, inflammatory bowel disease, foreign body, etc. Enterocutaneous fistula needs a multidisciplinary approach as its management is a very tedious and complex process. Sepsis, malnutrition, and dyselectrolytemia are three key factors during the management of enterocutaneous fistula, so these should be properly addressed for better and efficient outcomes. There is excess fistula effluent which should be replaced adequately in high output fistula. The nutrition of the patient plays a vital role in the success of enterocutaneous fistula management so if the patient can tolerate oral or enteral feeding should be commenced as soon as possible otherwise parenteral nutrition should be advised. Wound care should be done aggressively, proper skincare, timely drainage of any localised abscesses should be done. Patients should be properly resuscitated and stabilised before any definitive investigations and management. Surgical therapy can be staged and should not be rushed which results in failure of this complex disease process.

Transanal endoscopic operation for rectocutaneous fistula after low anterior resection: a case report

Introduction: Enterocutaneous fistulas (ECFs) can be caused by abscess formation at the site of anastomotic leakage (AL) after surgery. Rectocutaneous fistula following low anterior resection (LAR) is rare, and medical management of ECFs is usually the initial treatment. We report a case of rectocutaneous fistula after laparoscopic LAR, which was successfully treated, for the first time, with a transanal endoscopic operation (TEO). Case Presentation: A 58-year-old man presented with a history of hypertension, benign prostatic hyperplasia, peptic ulcer, and recent diagnosis of rectal cancer. The patient underwent laparoscopic LAR with coloanal anastomosis complicated with AL. He then underwent transanal repair of the anastomosis site and laparoscopy with ileostomy. Six months later, he complained of a painful mass lesion over the right buttock that relieved after passing purulent fluid and feces. Colonoscopy and imaging revealed a fistula for which he received antibiotics and wound incision and drainage. He also underwent TEO repair of the rectal fistula, recovered well, and was discharged from hospital. On follow-up 7 months later, there was no recurrence or sign of localized infection. Conclusion: TEO repair may be an effective method for managing rectocutaneous fistula after LAR complicated with AL instead of a major operation.

The Management of the Open Abdomen - A Literature Review.

An essential component of the concept of "Damage control surgery", laparostomy is the procedure by which the abdomen is deliberately abandoned open, the visceroperitoneal contents being temporarily protected by multiple technical means. Actual classification: Grade 1, without viscero-parietal adhesions or fixity of the abdominal wall (lateralization), divided into: 1A clean, 1B contaminated and 1C enteral fistula -cutaneous skin is considered clean); Grade 2, which develops fixation is subdivided into: 2A clean, 2B contaminated and 2C enteral fistula; Grade 3, "frozen abdomen", is divided into: 3A clean and 3B contaminated; Grade 4, defined as enteroatmospheric fistula, is a permanent fistula associated with the presence of granulation tissue and a frozen abdomen. Indications of the open abdomen are: damage control surgery, abdominal compartment syndrome, peritonitis, severe acute pancreatitis, vascular emergencies. Temporary abdominal closure may be achieved by following methods: skin only closure, â??Bogota bagâ?Â, opsite Sandwich technique, absorbable mesh, non-absorbable mesh or commercial zipper, vaccum asisted closure, each with its own advantages and disadvantages. Regarding the definitive closure this can be achieved by non mesh and mesh mediated techniques. Component separation technique anterior and posterior should be considered the elective repair procedure in parietal defects after laparostomy. Although several studies have been published, there is still no consensus in the literature on the positioning of prosthetic material in relation to parietal planes. Some authors suggest better results (relative to the rate of recurrence and complications) for implantation in the "sublay" position. Open abdomen is an important tool in the arsenal of the emergency surgery. Classification, indications, methods of temporary abdominal closure are evolving, as well as management of enterocutaneous fistulas and fascial closure, therefore permanent update is neccessary to offer patients the best care.

Spontaneous External Digestive Fistula of Tuberculosis Origin, Medical Treatment: About a Case at the Timbuktu Hospital

In the literature, the management of enterocutaneous fistula of tuberculosis origin is rare. The aim of this work was to report a case of external digestive fistula of tuberculosis origin in a 10-year-old girl in northern Mali in a situation of armed conflict. She was a 10-year-old patient who was admitted to our general surgery ward for external digestive fistula evolving for more than (4) four years, at admission the general. The karnofsky index was at 40%, she could not sit or hold a cup to drink water. A 3 cm enterocutaneous fistula deafened foul-smelling liquid stools, on clinical examination, the conjunctivas were pale, the lips were dry, the eyes were sunk in the eye sockets, the ribs visible from a distance. The paraclinical aspects (Itra-Dermo-Reaction (IDR) to tubercria, anatomopathology) were positive, specifying the place of medical treatment and evolution under medical treatment. Digestive fistula of tuberculosis origin is a rare condition in surgical settings.

Nutritional Management of Patients With Enterocutaneous Fistulas: Practice and Progression.

The management of enterocutaneous fistulas (ECF) can be challenging because of massive fluid loss, which can lead to electrolyte imbalance, severe dehydration, malnutrition and sepsis. Nutritional support plays a key role in the management and successful closure of ECF. The principle of nutritional support for patients with ECF should be giving enteral nutrition (EN) priority, supplemented by parenteral nutrition if necessary. Although total parenteral nutrition (TPN) may be indicated, use of enteral feeding should be advocated as early as possible if patients are tolerant to it, which can protect gut mucosal barrier and prevent bacterial translocation. A variety of methods of enteral nutrition have been developed such as fistuloclysis and relay perfusion. ECF can also be occluded by special devices and then EN can be implemented, including fibrin glue application, Over-The-Scope Clip placement and three-dimensional (3D)-printed patient-personalized fistula stent implantation. However, those above should not be conducted in acute fistulas, because tissues are edematous and perforation could easily occur.

Vacuum assisted closure system in the management of postoperative complex enterocutaneous fistulae: Postoperative Cohort Study‎

Background: There is controversy in the use of vacuum assisted closure therapy (VAC) in management of enterocutaneous fistula (ECF). Due to the increased risk of new fistula formation, its use was contraindicated, but then several studies reported successful closure, fistula effluent control and healing of excoriated skin by keeping it dry. Objectives: The aim of this study is to evaluate the efficacy of VAC in treatment of the complex postoperative ECF. Patient and Methods: Patients with postoperative ECF were enrolled in this prospective study in the period from January 2018 to June 2019. Full history, examination and investigations were done for all patients. Patients had VAC. After one month, responses to VAC in terms of time from fistula to VAC, general condition, fistula output, fistula closure, wound size, skin condition, time to start oral feeding, need to segregate, complications and mortality were recorded. On follow-up, time to complete closure, type of closure and cost were recorded. Results were then analyzed. Results: 60 patients with ECF were enrolled. General condition was improved in 32 patients while ECF output was improved in 52 patients. Early start of Oral feeding had occurred with the use of VAC. Complications as pain, new fistula formation, pulmonary embolism or ongoing sepsis occurred in 40 patients while mortality occurred in 12 patients. Conclusion: VAC is feasible in complex postoperative enterocutaneous fistulae. It enhances the survival, improves the general condition and the perifistular skin and reduces the fistula output and wound size.

Chronic enterocutaneous fistula: management in the community setting.

Despite being aggravating and potentially embarrassing, enterocutaneous fistulas can be successfully managed, with patients being able to resume many of their normal daily activities while the fistula continues to drain. Nevertheless, the management of enterocutaneous fistulas in the community can pose many challenges to nurses, the most common being peri-fistula moisture-associated skin damage. This article presents fistula management plans, which can facilitate the long-term support of these patients, promoting patient comfort and adherence to treatment.

Evaluation and Management of Enterocutaneous Fistula.

A 36-year-old woman presents with an abscess at her midline wound 4 weeks following an ileocecectomy for Crohn's disease. After the abscess is incised, there is purulent drainage followed by the drainage of enteric contents; the output is 750 mL per 24 hours.

Expert Commentary on the Management of Enterocutaneous Fistula.

Expert Commentary on the Management of Enterocutaneous Fistula.

P2.52: Complete Jejunal Exclusion: A novel method to manage Enterocutaneous Fistulas in the background of short bowel syndrome

Introduction: Management of enterocutaneous fistulas (ECF) in patients with short bowel syndrome (SBS) is challenging. High output fistulas are unlikely to close spontaneously; however, the success rate of surgical intervention is limited due to poor nutrition, inflammation, limited bowel length and lack of abdominal wall integrity. Here, we describe 8 cases of utilizing complete jejunal exclusion at the ligament of Treitz with a gastrostomy tube drainage to manage the ECF as a temporary measure for subsequent bowel reconstruction or transplant. To our knowledge, this is the first report of this approach. Methods: Eight patients who underwent jejunal exclusion at our institution were retrospectively reviewed. In all cases, the jejunum was divided 1–2 inches distal to the ligament of Treitz. Both ends were oversewn. A gastrostomy tube was placed for retrograde decompression of proximal enteric secretions without pyloroplasty. In 4 cases of active ECF’s, we accessed the ligament of Treitz via a left subcostal incision to avoid the fistula. Results: The procedure was done for active ECFs (n=4), impending fistulas (n=1), bridge to transplant following desmoid tumor resection in Gardner’s syndrome (n=2), and after graft enterectomy (n=1). Four cases of active ECFs were managed elsewhere without success. All patients were discharged home on TPN. Of the 4 ECF cases, the fistula output decreased substantially in all patients and closed entirely in 2 cases. Two underwent successful reconstruction and 2 are awaiting reconstruction. One who had secondary biliary cirrhosis due to biliary obstruction and TPN induced liver disease died while waiting for multivisceral transplant (MVT). Of the desmoid tumor cases, one underwent MVT, is alive and well 8 years after transplant, while the other refused to undergo MVT and is living with TPN and g-tube decompression 6 years after the procedure. The patient who underwent graft enterectomy is listed for MVT-this patient developed acute pancreatitis after the jejunal exclusion and required G-J tube decompression. Conclusions: Jejunal exclusion is an effective and generally well tolerated option in the management of intractable ECF in patients with SBS. Associated complications include pancreatitis and liver failure. This procedure should be considered as a bridge to intestinal rehabilitation or transplantation in patients with ECFs that fail to close with medical or traditional surgical management. Table:Picture:

Nurses Specialized in Wound, Ostomy and Continence Canada (NSWOCC) Management of Enterocutaneous Fistula and Enteroatmospheric Fistula: Development of Best Practice Recommendations.

Nurses Specialized in Wound, Ostomy and Continence Canada (NSWOCC) Management of Enterocutaneous Fistula and Enteroatmospheric Fistula: Development of Best Practice Recommendations.

Executive Summary: Nurses Specialized in Wound, Ostomy and Continence Canada (NSWOCC) Nursing Best Practice Recommendations: Enterocutaneous Fistula and Enteroatmospheric Fistula.

Enterocutaneous fistulas (ECF) and enteroatmospheric fistulas (EAF) pose significant quality-of-life concerns for patients, and management challenges for the interprofessional healthcare team. In 2009, the Canadian Association for Enterostomal The developed best practice recommendations for the management of ECF. Over time, evidence and practice evolve, and the Nurses Specialized in Wound, Ostomy and Continence Canada performed a comprehensive review of the literature and revised the practice recommendation document. The revised recommendations provide evidence-based management guidance for ECF and EAF in the adult population whether in acute care, community/home care, or long-term/residential settings, and are specifically created for nurses. The revised recommendations include organizational support, assessment, nutrition, pharmaceutical management, education, and local fistula management. This article serves as an executive summary for this clinical resource; the full guideline is available at http://nswoc.ca/ecf-best-practices/.

Rationale in management of entero-cutaneous fistula following routine and emergency surgery: a prospective study in a tertiary care hospital of Odisha

Background: The enterocutaneous fistula is an abnormal communication between gastrointestinal tract and skin. It is a grave surgical complication following surgery on gastrointestinal tract. Despite in surgical nutrition and critical care, mortality from enterocutaneous fistula remains high. Improvements in outcome are focused on prevention and when fistula occurs, prompt recognition and intervention is essential.Methods: This is institutional based prospective observational study which was conducted in S.C.B Medical college, Cuttack, Odisha for a period from September 2015 to September 2017 on 30 patients with enterocutaneous fistulae occurring as post-operative complication among patients admitted and operated at our institution for various gastrointestinal conditions and also referred from other centres after complication had set in. Detailed history, physical examination, routine workup, management and its outcome were studied.Results: The maximum number of fistulae (86.7%) developed after emergency surgery than routine. Incidence of enterocutaneous fistulae was observed in cases operated for intestinal obstruction (40%) followed by operation for enteric perforation (28%). The highest incidence of enterocutaneous fistula occurred on 8th post-operative day (36.7%). 24 cases were treated conservatively while 6 patients underwent operative treatment.Conclusions: Hence, the enterocutaneous fistula is frequently seen with emergency surgery of gastrointestinal tract, particularly on ileum, usually occurring around 8th post-operative day and most of them end in spontaneous closure with conservative treatment.

Systematic review: The role of somatostatin analogues in the management of enterocutaneous fistulae

Systematic review: The role of somatostatin analogues in the management of enterocutaneous fistulae

Current concepts in the management of enterocutaneous fistula

Enterocutaneous fistula is an abnormal connection between the intra-abdominal gastrointestinal tract and skin. It causes considerable morbidity and mortality. The goals of management are restoration of gastrointestinal continuity and allowance of enteral nutrition with minimal morbidity and mortality. A multidisciplinary approach is essential in the successful management and this has led to closure rates ranging from 5-20% following conservative management and 75-85% with operative treatment. This article seeks to review the current concepts in the management of enterocutaneous fistula. A systematic search of literature on enterocutaneous fistula was conducted. Relevant materials were selected and selected references from relevant books, journal articles and abstracts using Medline, Google scholar and Pubmed databases were critically reviewed. Enterocutaneous fistulas can be classified by the anatomy, aetiology or physiology. Anatomically, enterocutaneous fistula has been classified based on the organ of origin and this is useful in the consideration of management options: type l (abdominal oesophageal and gastroduodenal fistula), type ll (small bowel fistula), type lll (large bowel fistula) and type IV (enteroatmospheric, regardless of origin. The anatomy also depends on the presence or absence of associated abscess cavity and the length and characteristics of the fistula tract. Aetiologically, the majority of enterocutaneous fistulas are iatrogenic (75-85%) while between 15 and 25% occur spontaneously. The physiological classification is based on the volume of its output. High output fistulas drain more than 500mls in 24 hours, moderate output between 200 and 500mls in 24 hours and low output less than 200mls in 24 hours. Successful management requires a multidisciplinary approach and would consist of initial resuscitaion with fluids and electrolytes, control of sepsis, good and adequate nutrition, wound care and skin protection and definitive management. The treatment of enterocutaneous fistula is multidisciplinary and remains a challenge despite the recent improvement in supportive care. Once enterocutaneous fistula occurs, adequate stabilization of the patient and non-operative management should be commenced. If surgery is required, careful planning, meticulous dissection, restoration of bowel continuity and reconstruction of abdominal wall are critical.