Enterocutaneous Fistula: Medical and Surgical Management Including Patients with Crohn's Disease

Abstract

Patients with inflammatory bowel disease (IBD) and especially Crohn's disease can be challenging for even the most seasoned of surgeons. Development of an enterocutaneous fistula (ECF) in these patients further adds a level of complexity that requires a well-planned and defined management strategy. The role of the surgeon in caring for these patients should be as the leader of a multidisciplinary team, directing the care of the other specialists, all while determining if, and when, the patient requires operative intervention. Although medical management has come a long way in these and similar patients, surgery is still needed in a vast majority of patients. Therefore, understanding the evaluation, initial management, and important technical considerations for care of IBD and other complex patients with ECFs is a difficult, yet much needed, task for which the surgeon should be prepared. KEYWORDS: Enterocutaneous fistula, inflammatory bowel disease, Crohn's diseaseObjectives: Upon conclusion of this article, the reader should have a thorough understanding of the medical and surgical principles for managing enterocutaneous fistulas (ECFs) including: (1) the importance of a multidisciplinary approach; (2) early management of ECFs; and (3) the unique challenges patients with underlying inflammatory bowel disease provide.Enterocutaneous fistulas (ECFs) are abnormal connections between the gastrointestinal tract and the skin. The majority ( 85%) of ECFs develop following abdominal surgery for intestinal malignancy, inflammatory bowel disease (IBD), recurrent explorations, or after extensive adhesiolysis for conditions such as small bowel obstruction. The remaining 15% form spontaneously secondary to IBD (Crohn's disease >indeterminate colitis >ulcerative colitis), radiation enteritis, diverticular disease, perforated malignancy, intraabdominal sepsis, and abdominal trauma. Although the origin of the ECF can be essentially anywhere along the gastrointestinal (GI) tract, they most commonly arise from small bowel, colon, stomach, and duodenum in decreasing order. 1,2 As spelled out elsewhere in this issue, the management of the ECF requires a multidisciplinary approach, which will often necessitate aggressive medical and surgical management to try to minimize morbidity and mortality. This is especially true in those patients with underlying inflammatory bowel disease, where the potential for a lifetime of disease recurrence and future function must always be considered. Despite the wide range of underlying causes and patient clinical presentations, some basic tenants must be adhered to

Enterocutaneous fistulas and Crohn's disease: Clinical characteristics and response to treatment

“…ECF rarely responds to medical treatment and a high percentage of patients ultimately require surgical treatment (1)(2)(3)(4)(5). If the fistula is postoperative and occurs within the first 7 days, re-do surgery will be required.…”

“…They are seen in between 13 and 48% of patients, with a cumulative risk of 33 and 50% at 10 and 20 years after diagnosis, respectively. They are classified as internal when they communicate between two viscera and external when they originate in the ileum or colon and terminate in the skin (1).…”

Surgical treatment of patients with enteric fistulae

“…Залог успеха хирургического лечения во многом определяется правильно выбранным сроком опера-ции [6,8,9]. Оценить степень готовности больного к операции по показателям водно-электролитного ба-ланса, коррекции энергетических потребностей не-сложно, поскольку для этого существуют объектив-ные лабораторные тесты [13,14].…”

“…Труднее опреде-лить степень готовности к операции кишечной стенки и брюшины. На момент операции воспали-тельная инфильтрация кишечной стенки должна отсутствовать или быть минимальной [5,9,11]. Фиксация париетальных и висцеральных листков брюшины между собой должна позволять разделять кишечные петли с минимальной травмой за счет обозначившегося «слоя» между листками брюши-ны.…”

Fistula Output Microorganism-Susceptible Antimicrobial Prophylaxis Is Associated with a Lower Risk of Surgical Site Infection in Gastrointestinal Fistula Patients Undergoing One-Stage Definitive Surgery

“…The etiology of intestinal fistula is complex: the majority (75%-85%) of cases are secondary to iatrogenic injury, such as intra-abdominal operations for the treatment of inflammatory bowel disease [1]. The morbidity and mortality of GI fistula is variable, mainly depending on location of abnormal GI opening and underlying surgical or medical conditions [2].…”