Management of enterocutaneous fistulas

Abstract

Despite advances in antimicrobial chemotherapy, nutritional support, and perioperative critical care, the development of an enterocutaneous fistula continues to represent a major therapeutic challenge, with appreciable morbidity and mortality. Specific problems that must be addressed for the successful management of patients with enterocutaneous fistulas are the control of sepsis, maintenance of adequate fluid and electrolyte balance, provision of adequate and complication-free nutritional support, and skin-stoma care. In addition, many patients with postoperative intestinal fistulation suffer from significant psychological morbidity, which must be addressed during often prolonged periods of rehabilitation. The complex nature of the care required for successful management of patients with enterocutaneous fistulas mandates a multidisciplinary team approach, with specialist nurses, dieticians, pharmacists, radiologists, physicians, and surgeons all having important roles to play.

Keywords: Sepsis; fistuloclysis; laparostomy; parenteral nutrition.

Figure 1

Interrelationship between sepsis, nutritional depletion, impaired healing, and death in patients with enterocutaneous fistulas. MOFS, multiple organ failure syndrome.

Figure 2

Influence of sepsis on mortality from enterocutaneous fistula.

Figure 3

Radiological downstaging of a complex to a simple jejunocutaneous fistula. (A) Percutaneous drain has been inserted in associated abscess cavity (B, arrow), which subsequently collapses, resulting in a straight track to the jejunum (C).

Figure 4

Laparostomy wound at 6 weeks, showing small bowel loops densely covered with healthy granulation tissue.

Figure 5

Fistuloclysis. The catheter is sited in the distal limb of a small bowel loop prolapsing out of an almost completely healed laparostomy wound.

Figure 6

Prolapse of a small bowel fistula in an almost completely healed laparostomy wound. This appearance indicates that reconstructive surgery can now be safely undertaken.