Postoperative Enterocutaneous Fistula: When to Reoperate and How to Succeed

Abstract

An enterocutaneous fistula (ECF) is a potentially catastrophic postoperative complication. Although the morbidity and mortality associated with ECF have decreased over the past 50 years with modern medical and surgical care, the overall mortality is still surprisingly high, up to 39% in recent literature. It seems prudent, then, for every surgeon to have a thorough grasp of optimal treatment strategies for ECF to minimize their patients' mortality. Ultimately, the algorithm must begin with prevention. Once an ECF is diagnosed, the first step is to resuscitate and treat sepsis. The second is to control fistula output. The third step is to optimize the patient medically and nutritionally. The last step is definitive restoration of gastrointestinal continuity when necessary. Special mention is given in this article to exceptionally refractory fistulas such as those arising in the presence of inflammatory bowel disease and irradiated bowel. This plan gives a framework for the difficult task of successfully treating the postoperative ECF with a multidisciplinary approach.KEYWORDS: Enterocutaneous fistula, nutritional support, sepsis, radiation enteritis Objectives: Upon completion of this article, the reader should be able to summarize the management of postoperative enterocutaneous fistulas.

Enterocutaneous Fistulas: A Look at Causes and Management

“…The literature confirms that they are associated with decreased output and a decreased time to closure in highly favorable fistulas that are most likely destined to close without surgery [2,11,42], but not necessarily increased non-operative closure rate [43][44][45][46]. Some studies document utility in higher output fistulas to help minimize fluid and electrolyte loss and protect the skin.…”

“…While results have been largely disappointing, there seems to be some utility in carefully selected patients with favorable fistula anatomy and physiology [2]. It should be noted that this treatment modality carries attendant risk of allergic reaction, prion transmission and air embolism if injected under pressure [43].…”

“…If successful, diet is advanced and nutritional support is weaned slowly then discontinued when the patient consumes at least 70 % of their protein and caloric requirements. 90 % of fistulas destined to close spontaneously will do so in within this period [7,43]. In reality, this only occurs in approximately 30 % of fistulas [8, 54 • , 55].…”

Retrospective analysis of the effects of continuous intraluminal aspiration on postoperative intestinal fistulas

“…Preoperative requirements may take up to 6 months to fulfil, and it is not unreasonable to wait that long to progress to definitive surgical intervention [32]. Recommendations vary but usually specify waiting 3 to 6 months or longer after the original operation [31][32][33].…”

Ileocutaneous fistula with distal ileal narrowing treated with an esophageal stent

“…The patient remains asymptomatic 1 year later. Distal strictures are a cause of non-healing enterocutaneous fistulas [1]. In this case, it is likely that the adhesions caused a fixed loop that acted like a stricture, causing stagnation and increased backflow through the fistula, and this presumably was the cause of the fistula failing to heal.…”