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Home : Top directory : / Short topics / Colorectal / Entero Cutaneous fistula

Entero Cutaneous fistula

Author:Lengyel J.
on 25 Jul, 2007

Last edited by: Lengyel J. on 13 Aug, 2007
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Entero Cutaneous Fistula
 
 
Source: Surgery of the anus, recrum and colon. Keighley and Williams. Second edition Vol2
 
General statement: Patients survive following huge investments in time and involvement of a team who are able to provide specialist advice. It is NOT a quick fix will cure approach
 
Classification
 
  • Spontaneous or post operative
  • Simple or complex
  • High or low output
 
Aetiology
            Apply the surgical sieve.
 
  • Post operative
    • Commonest cause
    • Anastamotic failure
    • Beware early operation and adhesiolysis for small bowel obstruction
  • Congenital
    • Rare but the do occur
  • Trauma
  • Infection
    • TB
    • Actinomycosis israelii ( non sporing obligate anaerobes)
  • Inflammation
    • Crohns
      • 30% all enterocutaneous fistulae are due to Crohn’s
      • These may be spontaneous +/- abscess prior to discharge onto the skin. They usually have distal obstructive disease
      • Post operative. Usually no distal obstruction.
    • Diverticular disease
  • Neoplasm
    • Often here there is localised perforation then tracking to the skin from an abscess cavity
  • Radiation damage
 
 
Clinically
            Often SIRS develops first. Then skin shows signs of abscess formation then pus discharges followed by faecal contents.
 
 
 
Considerations:
  •  Mortality
    • follows sepsis
    • experience! Published studies with aggressive management have mortality rates >50% . Those that involoved a conservative approach with TPN 3% has been reported
    • Old tend to have worse outcomes
    • Disease process
      • Ischaemia >50%
      • Cancer / Radiotherapty >40%
      • Diverticular disease ~20%
      • Crohn’s 10%
      •  
  • Morbidity
    • Sepsis
    • Malnutrition
    • Fluid and electrolyte imbalance
    • Skin excoriation
    • Psychological impact on the patient and the STAFF!!
    • Financial costs can be huge
 
  • Natural history
 
    • The volume of output has no bearing whether the fistula would close spontaneously
    • Post op fistula’s will close in 70% with conservative management
    • Most do in 4-6 weeks. Failure to do so THINK distal obstruction?
    • Spontaneuos closue is low for
      • Cancer fistula’s             25%
      • Radiation injury             14%
      • Crohn’s                         8%
 
Management
 
How would you therefore manage a fistula?
 
Principles
1)   Resuscitate and control fistula discharge
2)   Elimination of sepsis
3)   Parental nutrition
4)   Rehabilitation and ambulation
5)   Define the anatomy of the fistula
6)   Definitive surgical procedure if indicated
7)   This is a TEAM approach
 
 
 
 
 
 
 
Resuscitate and control fistula discharge
 
            NGT
            Catheter
            Input /output charts
            Correct electrolyte imbalance
 
            Somatostatin analogues – octreotide
                       
 
Elimination of sepsis
            Peritonitis – Laparotomy +/- laparostomy
                                    Stoma
            Pus – percutaneous drainage
 
Parental nutrition
            50kcal/kg/day = 3500kcal /day
            400mg/kg/day Nitrogen
            For proximal fistulas – consider distal feeding via jejunostomy
 
Rehabilitation and ambulation
            Psychological support and physio
           
Define the anatomy of the fistula
            Is there bowel continuity?
            Which bit is involved?
            Likely pathology?
            Distal obstruction?
 
            CT / enemas/ follow throughs / MRI
Definitive surgical procedure if indicated
           
·       TB – rifampicin, isonizid / ethambutol
o      If no improvement after 4-6 weeks treatment – resection
·       Actinomycosis – erythromycin!
·       Crohns –
o      Medical management
 
European Crohn’s and Colitis Organisation (ECCO) Consensus on the management of Crohn’s disease concerns treatment of active disease.
 
BSG guidelines 2005 do not advocate the use of Infliximab in fistulating crohns disease…..However NICE has issued guidance on the use of Infliximab in 2002
 
 
 
Patients who have severe active Crohn's disease. These patients will already be in very poor general health with weight loss and
sometimes fever, severe abdominal pain and usually frequent (3–4
or more) diarrhoeal stools daily. They may or may not be
developing new fistulae or have extra-intestinal manifestations of
the disease. This clinical definition normally corresponds to a
Crohn’s Disease Activity Index (CDAI) score of 300 or more and
a Harvey-Bradshaw Index of 8/9 or above
 
They refer to the ACCENT II Trial:

In complex peri anal fistulating crohns....2/3 of fistulae will show response in 3/12
Of these 33% closed with continuing maintainance therapy
               20% closed with placebo

Put another way 1/3 will not respond at all, and of those that do respond only do partially and 2/3 of these will have a persistent fistula at 1 year during the maintainance period ON treatment.


           
Surgery for Crohn’s
            Given the above only 10-20% will close with medical managemtn alone. Surgery to excise the effected segment is the only treatment likely to fully cure the patient.
 
 
·       Diverticular disease
o      Surgery
·       Cancer
o      Palliative surgery
·       Radiation
o      Remember only 14% close on their own
o      Resect to normal bowel and anastamose
·       Post operative
o      Wait and then wait some more
o      Close at 6 months if possible.  
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