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INTRODUCTION
ABSTRACT The management of enterocutaneous fistula
Background: The management of enterocutaneous fistula (ECF) provides a supreme challenge for the general
(ECF) provides a supreme challenge for the general surgeon. surgeon. The development of intestinal drainage is
Methods: We conducted a retrospective review of all cases of never expected and is associated with infectious
complications, skin breakdown, nutritional compro-
patients with ECF referred to the surgical service from July
mise, and potential death. Aside from patients with
2007 to June 2011 to achieve a better understanding of the
inflammatory bowel disease, a malignancy that
factors that predict a successful outcome.
erodes the bowel wall, or direct trauma to the bowel
Results: A total of 35 patients were evaluated and managed in
in an open abdomen, nearly all ECFs are the result of
a systematic fashion that focused on treatment of abdominal surgical misadventure during abdominal surgery.1,2
sepsis, control of fistula output and wound management, Once an ECF occurs, the initial management requires
nutritional optimization, and operative intervention when elimination of any factor that would prevent sponta-
necessary. Age, gender, preoperative laboratory values, neous closure and promote ongoing intestinal drain-
etiology of ECF, and prior abdominal surgery for ECF were age to the skin. These factors are easily remembered
reviewed and compared. Fisher exact test was used to through the use of the mnemonic FRIEND that stands
compare patients who achieved a good outcome (n¼23) to for foreign body, radiation, inflammatory bowel
those with a poor outcome (n¼12) to determine factors that disease, epithelialization, neoplasia, and distal ob-
might predict their ultimate result. Two factors that predicted struction.3 Simultaneously with the elimination of the
poor outcome were the presence of abdominal malignancy FRIEND factors, the surgeon must focus the patient’s
(P¼0.01) and ECFs that occurred in trauma patients with an management on resuscitation, elimination of un-
open abdomen (P¼0.03). drained abdominal infection, control of intestinal
Conclusion: The etiology of ECF proved to be a more reliable output and skin protection, nutritional optimization,
predictor of outcome than clinical indicators. and eventual surgical correction if nonoperative
management fails to achieve spontaneous closure
within a reasonable period of time.
Numerous authors have summarized these prin-
Address correspondence to ciples of ECF management over the past decades,
George M. Fuhrman, MD but no one has contributed more to this field than
Department of Surgery Josef Fischer. Dr Fischer’s thoughtful approach to
Ochsner Clinic Foundation ECF patient management is succinctly summarized in
1514 Jefferson Hwy. a recent review.4 Strict adherence to Dr Fischer’s
New Orleans, LA 70121 principles of management can result in excellent
Tel: (504) 842-4070 patient outcomes; however, failure to restore intesti-
Fax: (504) 842-4013
nal integrity and the patient’s subsequent death are
Email: gfuhrman@ochsner.org
part of the reality for surgeons who manage these
Keywords: Intestinal fistula, parenteral nutrition—total, challenging patients. Large recently reported case
postoperative complications series demonstrate a spontaneous closure rate of
20%-37%, an 82%-91% success rate, and 8%-13%
The authors have no financial or proprietary interest in the subject mortality for patients with ECF managed in tertiary
matter of this article. referral hospitals.5-8 These results demonstrate the
challenges associated with the management of these reduction had not been dramatically achieved within
patients. 1 month of presentation and the preceding manage-
ment priorities had been addressed, patients were
METHODS scheduled for corrective surgery. The only situation
We reviewed our recent experience with ECF that argued for a delay in operation beyond 4 to 6
management to better understand the factors that weeks after presentation was a patient with a
predict successful outcomes in patients with ECF. particularly hostile abdomen at the sentinel opera-
We reviewed the records of all patients with ECF tion that resulted in the ECF. A particularly hostile
referred to our surgical service from July 2007 to abdomen argues for additional delay before consid-
June 2011. The surgical service at Atlanta Medical ering reoperation. A review of all prior operative
Center provides comprehensive care to a patient
records and direct communication with prior operat-
population in an inner-city hospital. Subspecialty
ing surgeons were considered essential to ade-
surgical services are not typical at this hospital. A
quately prepare for a reoperation.
total of 35 patients were identified. Patients were
At operation, a complete assessment of the
evaluated and managed in a systematic fashion that
focused on treatment of abdominal sepsis, control of gastrointestinal tract with lysis of adhesions from
ECF output, wound management, nutritional optimi- stomach to rectum was performed to ensure that any
zation, and operative intervention when necessary. distal obstruction was eliminated. Once the site of
Once a patient with ECF was admitted to the surgical ECF origin was identified and distal obstruction
service and adequately resuscitated, a routine eliminated, the source was resected, and a hand-
algorithm was employed to manage the condition. sewn, single-layer silk suture bowel anastomosis
First, a computed tomography (CT) scan of the was performed. The authors prefer the resection and
abdomen and pelvis was performed to rule out the hand-sewn anastomosis technique to suture repair
presence of undrained intestinal contents. Intestinal of the ECF or stapled anastomotic techniques
contents noted by CT were drained by percutaneous because evidence suggests superior outcomes.20
techniques.9,10 The liberal use of follow-up CT A decompressive gastrostomy was routinely
imaging was necessary to ensure complete drain- employed and was transitioned to a feeding tube if
age. necessary. Because the primary goal of this opera-
Once abdominal sepsis was controlled, enteros- tion was to achieve intestinal continuity and allow the
tomal therapists and wound care nurses were patient to regain the ability to eat and independently
enlisted to help develop strategies to control ECF achieve positive nitrogen balance, complex closure
output and protect the surrounding skin.11-13 Closed of the abdominal wall was deferred until a later time.
vacuum systems were often used to manage the Age, gender, preoperative laboratory values,
fistula output.14,15 Nonadherent dressings between etiology, and location of the ECF were reviewed
the viscera and sponge helped minimize the possi- and compared. Serum albumin was chosen as a
bility of creating new ECFs during dressing changes. marker of nutritional status in the weeks preceding
Administering octreotide16,17 and limiting oral intake surgical intervention. Creatinine was chosen as a
helped reduce the volume of ECF output. gauge of renal function. Ongoing inflammation level
After control of abdominal sepsis and wound
and acute nutritional status were evaluated by the
management were achieved, the next priority in
white blood cell count. Bone marrow function was
patient management was nutritional optimization.
evaluated with platelet count. Prior abdominal sur-
While total parenteral nutrition was always required,
gery for ECF, an ECF associated with a malignancy,
a transition to enteral nutrition was important for
and an ECF resulting from trauma were also
maintaining gut integrity. Maintaining gut integrity
was considered vital to maximize the success for the compared between the outcome groups.
intestinal anastomosis that might be required for A successful outcome was defined as patients
definitive surgical management of ECF.18,19 Feeding regaining the ability to eat normally, maintaining a
tubes were placed via the nose or endoscopically in positive nitrogen balance without supplementation
the stomach when patients had a functioning based on serum albumin and total protein levels, and
gastrointestinal tract but lacked the ability or desire functioning independently at home after hospital
to ingest calories. discharge. A poor outcome was defined as anything
Once controllable factors that prevent ECF less. Patients who achieved a good outcome were
resolution had been addressed and the abdominal compared to those with a poor outcome to deter-
sepsis, wound control, and nutritional status had mine factors that might predict their ultimate result.
been optimized, the likelihood of spontaneous Fisher exact test was used for statistical analysis,
resolution was assessed. In general, if ECF output with a P value of less than 0.05 defining significance.
homebound with a persistent ECF that is managed C-reactive protein levels. Therefore, despite nutri-
with excellent wound care. The patient has refused tional supplementation with total parenteral nutrition,
consideration of another corrective procedure. these patients continued to preferentially manufac-
ture acute-phase reactants rather than stores of
DISCUSSION albumin. Without nutritional stores dedicated to
The goal in managing patients with ECF is to healing after ECF resection, all 3 patients had a
restore intestinal continuity with the intention of recurrence of their ECF that ultimately contributed to
reestablishing independence and tolerance of an oral their demise. Ramsay and Mejia report using
diet. This goal was achieved in 65.7% of patients in catheters to drain an enteroatmospheric fistula
this review. The failure rate for this series is inferior to through the lateral intact abdominal wall. 26 By
the rates reported by other investigators; however, we redirecting the enteric contents away from the open
believe that the results reflect the management of a abdomen, success can be achieved. This technique
particularly challenging group of patients, reflected in may be a potentially attractive alternative to the
the 5.7% rate of spontaneous ECF closure in this approach used in this series.
series. This rate is dramatically less than other reports
and reflects a referral pattern that results in receiving CONCLUSION
patients for whom conservative management was A systematic approach to the treatment of ECF is
unsuccessful prior to patient transfer.5-8 When the 2 critical. Even with adherence to the algorithm of
most challenging subgroups of patients are excluded
intraabdominal sepsis control, wound management,
(trauma and malignancy), we achieved an 82.1%
and nutritional optimization, poor outcomes cannot
good result for patients with ECF, which is compara-
be avoided. Our retrospective review showed that
ble with other series. The uniformly poor outcome for
clinical indicators failed to predict the likelihood of
advanced malignancy and trauma patients in our
successful treatment. Instead, the etiology of ECF
study argues for a reevaluation of the management
proved to be a more reliable predictor of outcome.
approach in these especially challenging patients.
Our results show that an alternate approach to
Patients with advanced malignancy are difficult to
optimize nutritionally given the starvation state that managing ECF in trauma patients and in patients
may be present.21 Both patients in the poor-outcome with uncontrolled abdominal malignancy is warrant-
group who suffered from advanced abdominal malig- ed. Catheter drainage through the lateral intact
nancies could never be nutritionally optimized for abdominal wall in enteroatmospheric fistulas and a
surgical resection of the ECF. Cancer is a recognized minimalist approach in patients with advanced
etiology of fistula, but the underlying disease process malignancy may be more appropriate than a major
can preclude successful treatment of ECF either by complex reoperation. Thoughtful analysis of out-
resolution or surgical resection. Unless the primary comes is critical to achieving performance improve-
malignant process can be completely resected, ment in the future. While prevention is the best
attempted surgical resection is unlikely to result in treatment for ECF, a thoughtful and committed
cure of the ECF. Despite the poor outcomes in such approach to patient management will help ensure
patients, the principles of palliative surgical care lead the best possible outcome.
to referral of these patients because their ECF is often
the primary symptom impacting their quality of REFERENCES
life.22,23 Strong consideration for the use of palliative 1. Fischer JE. The pathophysiology of enterocutaneous fistulas.
octreotide to reduce gastrointestinal secretions and a World J Surg. 1983 Jul;7(4):446-450.
decompressive gastrostomy tube to avoid nausea 2. González-Pinto I, González EM. Optimising the treatment of upper
and vomiting might be a preferred option.22-24 gastrointestinal fistulae. Gut. 2001 Dec;49 Suppl 4:iv22-iv31.
The 3 patients with an ECF after blunt abdominal 3. Fisher S. Enterocutaneous fistula. In: Millikan KW, Saclarides TJ,
trauma with gastrointestinal contamination had a eds. Common Surgical Disease: An Algorithmic Approach to
Problem Solving. New York, NY: Springer-Verlag; 1998:164-167.
loss of abdominal domain when their abdomens
4. Evenson AR, Fischer JE. Current management of enterocutaneous
were left open. Exposed bowel without overlying
fistula. J Gastrointest Surg. 2006 Mar;10(3):455-464.
protective soft tissues is vulnerable to an enterotomy
5. Visschers RG, Olde Damink SW, Winkens B, Soeters PB, van
or desiccation with epithelialization of a fistula tract.25 Gemert WG. Treatment strategies in 135 consecutive patients
This unique entity of ECF, termed by some as an with enterocutaneous fistulas. World J Surg. 2008 Mar;32(3):
enteroatmospheric fistula, has been recognized as 445-453.
resistant to conservative management techniques 6. Brenner M, Clayton JL, Tillou A, Hiatt JR, Cryer HG. Risk factors
that are successful in other ECFs. The loss of native for recurrence after repair of enterocutaneous fistula. Arch Surg.
tissue barriers is compounded by the chronic 2009 Jun;144(6):500-505. Erratum in: Arch Surg. 2010 Jan;
inflammatory state characterized by elevated 145(1):10.
7. Hollington P, Mawdsley J, Lim W, Gabe SM, Forbes A, Windsor 16. Dorta G. Role of octreotide and somatostatin in the treatment of
AJ. An 11-year experience of enterocutaneous fistula. Br J Surg. intestinal fistulae. Digestion. 1999;60 Suppl 2:53-56.
2004 Dec;91(12):1646-1651. 17. Alivizatos V, Felekis D, Zorbalas A. Evaluation of the effectiveness
8. Draus JM Jr, Huss SA, Harty NJ, Cheadle WG, Larson GM. of octreotide in the conservative treatment of postoperative
Enterocutaneous fistula: are treatments improving? Surgery. enterocutaneous fistulas. Hepatogastroenterology. 2002 Jul-Aug;
2006 Oct;140(4):570-576; discussion 576-578. Epub 2006 Sep 49(46):1010-1012.
6. 18. Dudrick SJ, Maharaj AR, McKelvey AA. Artificial nutritional
9. McLean GK, Mackie JA, Freiman DB, Ring EJ. Enterocutaneous support in patients with gastrointestinal fistulas. World J Surg.
fistulae: interventional radiologic management. AJR Am J 1999 Jun;23(6):570-576.
Roentgenol. 1982 Apr;138(4):615-619. 19. Lloyd DA, Gabe SM, Windsor AC. Nutrition and management of
10. D’Harcour JB, Boverie JH, Dondelinger RF. Percutaneous enterocutaneous fistula. Br J Surg. 2006 Sep;93(9):1045-1055.
management of enterocutaneous fistulas. AJR Am J Roentgenol. 20. Lynch AC, Delaney CP, Senagore AJ, Connor JT, Remzi FH, Fazio
1996 Jul;167(1):33-38. VW. Clinical outcome and factors predictive of recurrence after
11. Hoedema RE, Suryadevara S. Enterostomal therapy and wound enterocutaneous fistula surgery. Ann Surg. 2004 Nov;240(5):
care of the enterocutaneous fistula patient. Clin Colon Rectal 825-831.
Surg. 2010 Sep;23(3):161-168. 21. Palesty JA, Dudrick SJ. What we have learned about cachexia in
12. McNaughton V; Canadian Association for Enterostomal Therapy gastrointestinal cancer. Dig Dis. 2003;21(3):198-213.
ECF Best Practice Recommendations Panel, Brown J, et al. 22. Blair SL, Chu DZ, Schwarz RE. Outcome of palliative operations
Summary of best practice recommendations for management of for malignant bowel obstruction in patients with peritoneal
enterocutaneous fistulae from the Canadian Association for carcinomatosis from nongynecological cancer. Ann Surg Oncol.
Enterostomal Therapy ECF Best Practice Recommendations 2001 Sep;8(8):632-637.
Panel. J Wound Ostomy Continence Nurs. 2010 Mar-Apr;37(2): 23. Dalal KM, Gollub MJ, Miner TJ, et al. Management of patients with
173-184. malignant bowel obstruction and stage IV colorectal cancer. J
13. Dearlove JL. Skin care management of gastrointestinal fistulas. Palliat Med. 2011 Jul;14(7):822-828. Epub 2011 May 19.
Surg Clin North Am. 1996 Oct;76(5):1095-109. 24. Hisanaga T, Shinjo T, Morita T, et al. Multicenter prospective
14. Wainstein DE, Fernandez E, Gonzalez D, Chara O, Berkowski D. study on efficacy and safety of octreotide for inoperable
Treatment of high-output enterocutaneous fistulas with a malignant bowel obstruction. Jpn J Clin Oncol. 2010 Aug;40(8):
vacuum-compaction device. A ten-year experience. World J Surg. 739-745. Epub 2010 Apr 21.
2008 Mar;32(3):430-435. Erratum in: World J Surg. 2008 Mar; 25. Schein M, Decker GA. Gastrointestinal fistulas associated with
32(3):429. large abdominal wall defects: experience with 43 patients. Br J
15. Gunn LA, Follmar KE, Wong MS, Lettieri SC, Levin LS, Erdmann Surg. 1990 Jan;77(1):97-100.
D. Management of enterocutaneous fistulas using negative- 26. Ramsay PT, Mejia VA. Management of enteroatmospheric fistulae
pressure dressings. Ann Plast Surg. 2006 Dec;57(6):621-625. in the open abdomen. Am Surg. 2010 Jun;76(6):637-639.
This article meets the Accreditation Council for Graduate Medical Education and the American Board of
Medical Specialties Maintenance of Certification competencies for Patient Care and Medical Knowledge.