Surgical management of enterocutaneous fistula sukhwan lee, md, phd department of surgery, kyung hee university hospital at gangdong, kyung hee university school of medicine, seoul 4727, korea enterocutaneous ec fistula is an abnormal connection between the gastrointestinal gi tract and skin. In an era when the mortality from pancreaticoduodenectomy. The editors of the european journal of trauma and emergency surgery asked us to put together a focus issue on the current management of. As a result, contents of the stomach or intestines leak through to the skin. The management of patients with enterocutaneous fistula ecf requires an interdisciplinary approach and poses a significant challenge to physicians, woundstoma care specialists, dietitians, pharmacists, and other nutrition clinicians. It is therefore imperative that attention must be paid to welldesigned management protocols. An enterocutaneous fistula ecf is an aberrant connection between the intraabdominal gastrointestinal gi tract and skinwound. In surgical textbooks, enterocutaneous ec fistulas are described as surgical tragedies, catastrophes or disasters. A more liberal interpretation of the term, however, also includes enteric fistulas originating from the colon, stomach, and esophagus. Clinicians caring for this disease should be familiar with the overall approach to treating an enterocutaneous fistula. Current management of enterocutaneous fistulas article pdf available in european journal of trauma and emergency surgery 373. The use of latex catheters to close enterocutaneous. Considerations for the management of enterocutaneous fistula. In an era when the mortality from pancreaticoduodenectomy is less than 3%, the mortality of enterocutaneous fistulas remains 10 to 30% due to the oftenpresent complications of sepsis, malnutrition, and electrolyte.
Nutritional management of enterocutaneous fistulas british. Care of these patients should focus on four keys phases. Guided treatment improves outcome of patients with enterocutaneous fistulas guided treatment improves outcome of patients with enterocutaneous fistulas. Patients with a recent 10% to 15% weight loss andor an albumin level enterocutaneous fistula. Building up nutrition, to make the patient fit to tolerate second procedure. Significant advances have been made over and the treatment paradigm has evolved. The testtaker is required to have an understanding of fistulas managed with medical management and those requiring surgical intervention. Abstract one of the most devastating complications to develop in the general surgical patient is an enterocutaneous fistula ecf. Pdf current concepts in the management of enterocutaneous fistula. Surgical management of high output enterocutaneous. Procedures performed for malignancy, inflammatory bowel disease, or adhe siolysis are. Open abdominal wounds with enterocutaneous fistulae present health care providers and patients with complex wound management issues.
It is one of the most disheartening experiences to both the surgeon and the physician. A look at causes and management enterocutaneous fistulas. Enterocutaneous fistula is an abnormal connection between the. Critically ill patients suffering trauma, thermal injury, and other acute intra abdominal pathology are at unique risk for this complication as well.
Cureus bronchoperitoneal and enterocutaneous fistula. Conversion of an enterocutaneous fistula associated with. Although definitive treatment frequently relies on surgical closure, preoperative care and diligence is paramount to ensure a successful outcome. Fistulas that originate in between these locations may not allow enough enteral absorption proximal to the fistula and can be managed using fistuloclysis, no. Because of differences in management and significant preponderance of small intestinal and colonic fistulae, fistulae originating in the rectum, upper gi tract, or pancreas will not be discussed in this article. Nutrition and management of enterocutaneous fistula. Review article current management of enterocutaneous fistula amy r. The goals of management are restoration of gastrointestinal continuity and allowance of enteral nutrition with minimal morbidity and mortality.
The use of latex catheters to close enterocutaneous fistulas. The etiology of enterocutaneous fistula predicts outcome. There is usually a delay in diagnosis, and treatment recommendations are mainly derived from case reports. Current surgical management of enterocutaneous fistulas. Full text nutritional management of enterocutaneous fistula. Treatment of ecfs is difficult because only approximately 30% will close with medical management and there is significant morbidity and mortality associated with surgical intervention 3, 4. Pdf current concepts in the management of enterocutaneous.
Enterocutaneous fistula is an abnormal connection between the gastrointestinal tract and skin. Enterocutaneous fistulas ecfs are a complex problem with high associated morbidity and mortality. Anatomic classifications divide fistulas into internal and external fistulas, identify the organs involved, and provide characteristics of the. Current concepts in the management of enterocutaneous fistula. Enterocutaneous fistulae ecf are challenging surgical problems. Managing complex, highoutput, enterocutaneous fistulas. Pdf enterocutaneous fistula is an abnormal connection between the intraabdominal gastrointestinal tract and skin. A fistula is an abnormal communication between 2 epithelialized surfaces, with an enterocutaneous fistula ecf being an abnormal communication between the small or large bowel and the skin. Considerations for the management of enterocutaneous. Guidelines for optimizing nutrition status in these patients are often vague, based on limited and dated clinical studies, and typically rely on.
Mar 29, 2011 with this in mind, we set to create a series of articles that will meet one aim. Enterocutaneous fistula is an abnormal connection between the intraabdominal gastrointestinal tract and skin. Bronchoperitoneal fistulas are rare but serious pathologies that pose numerous treatment challenges to physicians. May 22, 2017 the management is heavily influenced by the underlying aetiology and the anatomical classification of the fistula, which together determine the likelihood of resolution without surgical intervention. High output enterocutaneous fistula is a very difficult condition to manage and the surgical intervention in severe malnutrition cases after conservative management for keywords. Current management of enterocutaneous fistula semantic. Enteroatmospheric fistulas, which are a subset of enterocutaneous fistulas. Fistula care is one of the most challenging aspects within the wocncb certified nurse role. These recommendations are a comprehensive resource summarizing the current literature that supports the care of the person with an enterocutaneous fistula.
Parenteral nutrition has long been recognized to be an integral part of the management of enterocutaneous fistulas. Enterocutaneous fistulas may be categorized by anatomic, physiologic, or etiologic criteria, all of which may influence the patients course and the likelihood of spontaneous closure of the fistula. Korean j radiol suppl 1, janfeb 2012 s19 surgical management of enterocutaneous fistula determining the optimal time for surgical intervention has not been well defined in the literature. Nutritional management in enterocutaneous fistula dr deepak govil ms, phd gi surgery senior consultant surgical gastroenterology indraprastha apollo hospital. Surgical management of enterocutaneous fistula sukhwan lee, md, phd department of surgery, kyung hee university hospital at gangdong, kyung hee university school of. Pdf enterocutaneous fistula is an abnormal connection between the intra abdominal gastrointestinal tract and skin. Management includes early recognition and treatment of sepsis, reducing fluid and electrolyte homeostasis, nutrition support, wound management and a carefully timed surgical procedure. Current management of enterocutaneous fistula springerlink. The editors of the european journal of trauma and emergency surgery asked us to put together a focus issue on the current management of gastroenterocutaneous fistulas. The poor outcomes of medical and surgical management have led to a need for minimally invasive. Here, we present an interesting case of a patient who developed a left bronchoperitoneal fistula and two subsequent enterocutaneous fistulas resulting from a massive intra. The mean interval since resection is 46 years range nine months to 10 years.
Adalimumab an effective and promising treatment for patients with. The management of enterocutaneous fistula is challenging, with significant associated morbidity and mortality. An enterocutaneous fistula ecf is an aberrant connection between the gastrointestinal tract and the skin or atmosphere enteroatmospheric fistula eaf. The development of an enterocutaneous fistula has frequently been reported as being attended by a high morbidity and mortality, particularly in patients with inflammatory bowel disease who have high output, small bowel fistulas. Depending on the site of the fistula and the nutritional status of the patient, clinicians have to decide whether parenteral nutrition or enteral nutrition should be established. When referred there were recurrent fistulae with extensive abdominal sepsis and severe metabolic. Sep 27, 20 ecf treatment is complex and based on various assessments, treatment can be medicalconservative management or surgical. Relevant articles were identified using medline searches. Enteroatmospheric fistulas, which are a subset of enterocutaneous fistulas that occur in the setting of an open abdomen, are also discussed here. Patients with fistulas require coordinated, interdisciplinary care including services of a certified woc nurse, dietitian, social worker, pharmacist, nurse, surgeon, and physician.
Srinivasan emory university hospital, 64 clifton rd ne, atlanta, ga 30322, usa despite advances in medical technology and surgical care, the management of enterocutaneous fistulas remains one. Nutritional management of enterocutaneous fistulas case i n june 2009, a 40yearold male was admitted to an outside institution after developing a partial small bowel obstruction secondary to multiple abdominal incisional hernias that required repair. Enterocutaneous fistulas still have a high unacceptable mortality rate and their management is very complex and is a big challenge to the surgeon. Although most fistulae occur as a complication of surgery, 15%25% may occur spontaneously in patients with inflammatory bowel disease or cancer. An enterocutaneous fistula ecf is an abnormal connection that develops between the intestinal tract or stomach and the skin.
The principles of management are well established and begin with resuscitation, sepsis control, nutritional support, anatomical characterization, and adequate drainage of fistula effluent. Current management of enterocutaneous fistulas pdf. The wound, ostomy and continence nurses society wocn. A look at causes and management, current surgery reports on deepdyve, the largest online rental service for scholarly research with thousands of academic publications available at your fingertips. A metaanalysis of the current literature leading to a set of management goals that enables the professional nurse to provide care that improves the quality of life of persons living with an enterocutaneous fistula ecf in all care settings. Enterocutaneous fistulas are challenging for general surgeons, the extended mdt team, and members of the patients family. In an era when the mortality from pancreaticoduodenectomy is less than 3%, the mortality of enterocutaneous fistulas remains 10 to 30% due to the oftenpresent complications of sepsis, malnutrition, and electrolyte abnormalities. Martinez jl, luquedeleon e, ballinasoseguera g, mendez jd, juarezoropeza ma, romanramos r. Enterocutaneous fistula, high output fistula, surgical intervention, malnutrition cases.
In an era when the mortality from pancreaticoduodenectomy is less than 3%, the mortality of enterocutaneous fistulas remains 10 to 30%. It results in some serious complications that lead to prolonged hospitalization and high cost of. We report a series of 114 patients who required treatment for 2 fistulas during the period 19761981. Results a total of 35 patients were evaluated and managed in. Risk factors for recurrence after repair of enterocutaneous. The management of enterocutaneous fistula ecf is a clinical skill that should be in the armamentarium of every general surgeon. The management of an enterocutaneous fistula often presents a particular challenge for the woc nurse. An ecf can arise from the duodenum, jejunum, ileum, colon, or rectum. We evaluated our practice and compared our outcomes with previous results published from our institution. Apr 23, 2012 treatment of ec fistula remains a surgical challenge despite the recent improvement of supportive patient care.
Background the management of enterocutaneous fistula ecf provides a supreme challenge for the general surgeon. An enterocutaneous fistula also known as a gastrointestinal fistula is an abnormal opening between the stomach. There was one fistula related death in a 24 year old man with a selfinduced traumatic ileal fistula which had been oversewn. Current management of enterocutaneous fistula sciencedirect. Latifi and others published current management of enterocutaneous fistulas find, read and cite all the research you need on. In spite of the advances made in critical care, antibiotics and nutritional support, the management of enterocutaneous fistula remains a challenge to surgeons today with mortality remaining at 515%. Management of enterocutaneous fistulaein crohns disease. Frequently, large wounds with exposed bowel are present and require the utilization of multiple wound care modalities to provide a method of control and isolation of fistula effluent to allow for maximum wound healing. Anatomic classifications divide fistulas into internal and external fistulas, identify the organs involved, and provide characteristics of the fistula tract. Enterocutaneous fistula is a devastating complication which has significant consequences for the patient and is challenging to treat. Pdf current management of enterocutaneous fistula amy. Enterocutaneous fistulas, defined as abnormal communications between bowel and skin, are among the most challenging conditions managed by the general surgeon.
Enterocutaneous and enteroatmospheric fistulas uptodate. This generalization proved especially true in the following case of a patient with an ileostomy and an enterocutaneous fistula who received salvage intravenous paclitaxel taxol chemotherapy. Treatment of enterocutaneous fistulas, then and now. Implementing a proforma for multidisciplinary management. The management of enterocutaneous fistula ecf is a clinical skill that should be in the. These 10 best practice recommendations are the result of answering the question what is the best way for the nurse to manage an adult patient living with an enterocutaneous fistula ecf. Gastrointestinal fistula is a pathological communication between the gastrointestinal tract and a hollow viscera internal fistula or the skin external fistula. Guidelines for optimizing nutrition status in these patients are often vague, based on limited. Despite recent advances in the management of these patients, the mortality rate ranges between 10 and 20%. Pdf a study on causes and management of enterocutaneous. Factors predictive of recurrence and mortality after surgical repair of enterocutaneous fistula. Current management of enterocutaneous fistulas pdf paperity. Strictly speaking, an enterocutaneous fistula connects the small bowel to the skin.
Once ec fistula occurs, adequate stabilization of the patient, a thorough investigation of the fistula anatomy, and nonoperative management should intially be attempted. Introduction enterocutaneous fistula ecf is an abnormal. Enterocutaneous fistulas, defined as abnormal communications between bowel and skin, are among the most challenging conditions managed by the general. Definitive surgical treatment of enterocutaneous fistula.
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