Postoperative enterocutaneous fistula - principles in non-operative approach

Abstract

IntroductionPostoperative enterocutaneous fistulae could constitute a challenge when they occur following an abdominal surgery. Astute application of correct principles in its management is essential for good outcomes.MethodsA retrospective review of records of patients with enterocutaneous fistulas managed non-operatively was done. Clinical assessment, anatomic and physiologic classification of fistula, fluid resuscitation, electrolyte correction, parenteral/enteral nutrition, antibiotic use and fistula effluent monitoring, formed the basis of management.Results(4/14)Four out of 14 patients with enterocutaneous fistulae were managed exclusively non-operatively. Their ages ranged between 34 and 63 years. Mean age 46years. All four fistulae occurred postoperatively. Laparatomy for ectopic pregnancy, bowel obstruction constituted the primary surgery. There were two high output cases and two low output cases. Initial parenteral nutrition was employed in two cases while enterals were used solely in two cases. Fistula closure was achieved in all 4 cases at durations ranging from 7 to 16 days, a mean time of 12.5 days.ConclusionNon-operative approach to management for postoperative enterocutaneous fistulas was successful in these cases.

Postoperative Enterocutaneous Fistula: A Severe and Desperate Complication in a Disadvantaged Surgical Setting

“…In general, these fistulas appear as early as the end of the first week after the initial surgery [3,4,12]. In our study, we noted extremes of 2 and 17 days.…”

“…In these contexts, ligatures, sutures and anastomoses performed in a highly septic environment are more likely to result in fistulas by loosening or simply leakage. It may also be an inadvertent opening of the coecum or ileum, a slipped stump ligature and a too low appendix stump amputation [4,12]. The increasing number of non-employed medical graduates in our country in the last ten years has contributed largely to the setting of clandestine medical clinics and the illegal practice of surgery by nonspecialized agents.…”

“…Re-intervention to heal the fistula is often indicated in situations of high output, persistence of the fistula, intraabdominal sepsis or associated evisceration [2][3][4][5][6]12]. The best time to perform this surgical procedure remains controversial.…”

Postoperative enterocutaneous fistulas: Management outcomes in 23 consecutive patients

“…Management of patient with enterocutaneous fistula is still represent one of major challenge and dilemma in general surgical practice [ 8 ].Although the management of such fistulas have been improved with better understanding of the anatomical,pathophysiological and metabolic derangement, better control sepsis, adequate nutritional support, and improvement in the critical care and the surgical treatment; the mortality rate is still high [ [9] , [10] , [11] ]The main concern in the treatment of enterocutaneous fistula is to enhance the spontaneous closure [ 10 ]. Although spontaneous closure occurs in some patients most of the cases need definite surgical intervention to excise the fistulous tract and to restore the continuity of intestine if the clinical and operative conditions permit [ [10] , [11] , [12] ].…”

“…Our findings are consistent with results of similar researches . [ 9 , 10 , 13 , 16 , 30 ]Death due to duodenal and Jejunal fistulas have been reported to have double the death rates associated with distal ileal and colonic fistulas due to higher effluent [ 27 ] ,31 . Several variables used clinically to judge the likelihood of spontaneous closure are illustrated in Table 6 .…”