Enterocutaneous Fistulas: A Look at Causes and Management

Abstract

Despite advances in medical technology and surgical care, the management of enterocutaneous fistulas remains one of the most challenging problems faced by physicians. Success depends on an expert multidisciplinary team, access to long-term enteral and parenteral nutrition support, advanced wound care, optimal medical management and meticulous, methodical, surgical decision-making and technique. Management is complex and multiphasic. Improved survival rates for many morbid problems have resulted in a growing population of patients with increasingly complex fistulas. This article reviews the etiologies as well as classic and evolving management strategies for this problem.

Enterocutaneous fistula: analysis of clinical outcomes from a single Victorian tertiary referral centre

“…Available evidence is scarce but it is the opinion of our institution that hand‐sewn anastomosis are more likely to produce a better outcome in terms of re‐fistulation and less risk of anastomotic leak in these challenging and complex cases. There are papers which concur with our opinion that hand‐sewn anastomosis is superior to stapled anastomosis in terms of reduction in recurrence. Although it is not statistically significant, among our three cases, which had stapled primary anastomosis, one case developed re‐fistulation.…”

“…suggested a waiting period of 12–36 months before attempting operative repair . Nevertheless, such prolonged delays are associated with increased risk of central‐line‐associated infections, cholestatic liver injury and increased risk of recurrent fistula …”

Current concepts in the management of enterocutaneous fistula

“…9 Broad spectrum antibiotics should be started at the onset of sepsis and cultures taken from all possible sources of infection. 22 Antibiotics should then be tailored to the results from culture and sensitivity and reserved for patients with ongoing sepsis with special consideration given to fungal infections. 12 The indiscriminate use of antibiotics should be avoided as this may lead to selection of highly resistant pathogens that may cause untreatable overwhelming infections.…”

“…29 Fistuloclysis (feeding through the fistula) has been described and is possible if the fistula is proximal enough to allow at least 5 feet of small bowel absorption to occur in the absence of distal obstruction. 22,30…”

“…2,[37][38][39] As a result of the fact that negative pressure therapy can cause bowel injury and lead to fistula formation, interposition of a layer of material between bowel and the sponge of the device when in use has been recommended as a cautionary measure. 22 The use of fibrin glue has been reported in carefully selected patients with favourable anatomy and physiology. 2,40 Only case series are available for fistula plugs in the treatment of enterocutaneous fistula.…”