Enterocutaneous Fistula (ECF)
Discuss ECF?
Enterocutaneous fistula is a feared complication of abdominal surgery. 75-85% of fistulas occur after surgery, although IBD, diverticulitis, radiotherapy, trauma, ischaemic bowel and malignancy commonly contribute. 15-25% fistulas occur spontaneously in association with IBD, cancer, radiation etc.
What are the conditions predisposing to postoperative fistulas?
- Bowel injury at surgery either iatrogenic or missed (as in trauma)
- Malnutrition, sepsis, shock, steroid therapy
- Technical difficulties with surgical anastomosis
It is important to determine the cause of fistula formation because it determines therapy. Fistulas that arise in IBD or cancer are unlikely to close spontaneously, whereas postop low output fistula (<500ml in 24 hr) arising from partial anastomotic dehiscence will frequently close with conservative management.
How do you manage enterocutaneous fistula?
- Fluid, electrolyte and nutritional management
- Fluid and electrolyte replacement.
- NPO till the patient is stable
- Reintroduce oral fluid and food once the patient is stable
- If the combined fistula and stomal faecal output is high- try and reduce the loss to a level at which IV fluid/nutrition is not required. This can be achieved by following the management principles of jejunostomy (see the relevant chapter). Once the output is successfully reduced, wean the pt of all nutritional and fluid support.
- If the output remains high- consider parenteral nutrition. Alternatively PN may be needed if the caloric requirements cannot be met by oral/enteral feeding. Feeding jejunostomy distal to the fistula may be an option.
- Early recognition and control of sepsis
A second cornerstone of early management is establishment of adequate drainage of external fistulas. If the fistula cannot be controlled, pooling of the fistula contents within the abdominal cavity can lead to infection/abscess formation. To avoid this complication percutaneous drains or opening a recent surgical incision may be needed. - Surgery usually involves en bloc resection of the involved bowel and overlying skin and anastomosis often with temporary defunctioning. Surgery is undertaken once (usually after 6 months) fistula matures and inflammation/sepsis has resolved along with optimisation of the pts nutritional state.
What is the prognosis?
Mortality rates have significantly improved from 65% to approximately 20%. Sepsis is a major cause of death.
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