Medical and surgical management of enterocutaneous fistula

Available online 17 October 2023, 100987

Author links open overlay panel, Abstract

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.

Section snippetsINTRODUCTION

Enterocutaneous fistula (ECF) remains a feared and debilitating complication of surgery. Most (80-90%) ECFs develop following abdominal surgery, however, inflammatory bowel disease, trauma, radiation exposure, and intra-abdominal malignancy also play an important role in de novo fistula formation.1 The annual incidence of ECF and the number of patients surviving with a fistula is not well understood, but the impact of ECF on a patient's life is substantial.2, 3 Patients who develop ECFs

HISTORY

Establishing a chronology of the events that led to fistula formation and the attempted treatments is fundamental to creating a comprehensive treatment strategy. Hospital encounters and operative records should be reviewed, and an attempt should be made to discuss the patient's case with the surgeon(s) present at the index/subsequent operations. As the care of patients with ECF is multi-disciplinary and often will be delivered at many locations, an accurate timeline should be documented in the

SEPSIS AND SKIN CARE

Sepsis as a result of intra-abdominal infection must be recognized early and aggressively treated. An important component of the initial evaluation includes cross-sectional imaging to rule out uncontrolled fistula output and resulting intra-abdominal fluid collections. When the priority is rapid evaluation, oral contrast can be omitted to expedite imaging. In the event there is an uncontrolled intra-abdominal collection, the clinical status of the patient and availability of consulting teams

ANATOMY OF THE FISTULA

Cross-sectional imaging provides a starting point for defining a fistula's anatomy. Computed tomography (CT) scans provide an overall survey of the surrounding anatomy and can be augmented by the administration of water-soluble contrast orally, rectally, and/or through the fistula tract itself when the source of the fistula is in question. Utilization of CT enterography (CTE) is done on a case-by-case basis and is particularly helpful to map out the extent of active disease in patients with

PROCEDURE DEVELOPMENT & PERIOPERATIVE SUPPORT

Following completion of the initial stages of the SNAP algorithm, surgical intervention for ECF becomes elective and subject to many of the usual constraints of elective operations. Optimization of modifiable risk factors that contribute to complications & recurrent fistula and allowing sufficient time for a hostile surgical field to settle takes precedence. During this transition, clear expectations of the timing of future workup and the potential of surgery should be communicated. The

CONCLUSION

While a challenging complication of surgery, a multi-disciplinary and holistic approach to ECF care can increase a patient's chance of successfully getting an elective ECF closure operation. Taking a methodical approach to the disease progress, establishing a strong therapeutic partnership with the patient, relying on the expertise of complimentary disciplines, and upholding stringent surgical standards when the opportunity comes to attempt closure all optimize the chance of a successful

Acknowledgements

N/A

Disclosure Statements

All authors (MA & JM) declare no relevant, actual, or potential financial, personal, or other conflicts of interest.

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