ManagementoftheComplicated

EnterocutaneousFistula

ChristopherD.Raeburn,MD
DepartmentofSurgeryGrandRounds
UniversityofColoradoHealthSciencesCenter
 TheQuestions:
Whatisafistula?Aretheyallthesame?
DoIneedtooperate?
WhenshouldIoperate?
WhenshouldIoperate
ShouldIreconstructthefasciaorcallitaday?
 ReallyHowbadisit?

Netherlands

135ptswithECF
21healedspontaneously
44died,13diedoffistula(9.7%)
62ptswithhealed ECFcomparedtomatched
controls
Howmuchisthisgonna setmeback?

Chicago

Evaluated13,454ptswithCrohns
PaidClaimsin12monthsafterDx withor
withoutfistula
 Fistuladoublescost
Inpt hospitalizationandSurgerymosteffected
Didnotaccountforindirectcostssuchaslost
workdays,lostearnings,outofpocketcosts
Includedperianal fistulasolikelyunderestimate
EnterocutaneousFistulaComplicatingTrauma
Laparotomy:AMajorResourceBurden
Retrospectivecasecontrolstudy
2373acutetraumalaparotomies
36(1.5%)developedECF
NoFistula
Fistula Pvalue
Controls
ICULOS(days) 28.530.5 7.69.3 0.004
TotalLOS(days) 82.1100.8 16.217.3 <0.001
HospitalCharges $539,309 $126,996 <0.001

Teixeira (USC), American Surgeon, 2009

 Whatisafistula?
Aretheyallthesame?
 Definitions
Fistula abnormalcommunicationbetween
twoepithelialized surfaces
Enterocutaneousfistula abnormal
communicationbetweenthe
bowellumenandskin
Causes
Post-surgical = 75-80%
Other = 20-25%
IBD
Malignancy
XRT
Diverticulitis
Trauma
 ClassificationSystems
Anatomic
stomach,duodenum,jejunum,ileum,colon
Etiologic
Postoperative,crohns disease,cancer,radiation
Physiologic
Low<200mL/d
Moderate=200500mL/d
High>500mL/d
WhyClassify?
Predictclosure?Mortality?
DoIneedtooperate?
 FRIEND

ForeignBody
Radiation
Inflammation/infection
Epithelialization
Neoplasm
DistalObstruction
 Brazil
188patientsover10yr
Spontaneousclosure31%
Mortality31%
Anatomic
Duodenal22%
Jejunoileal29%
Colonic24%
Biliopancreatic25%
Etiologic
Postoperative90%
Cancer29%
Physiologic
Low(<500mL/d)50%
High(>500mL/d)50%
 UnivariateAnalysis

p =0.017
MultivariateAnalysisfor
SpontaneousClosure
 MultivariateAnalysisforMortality

Summary
Duodenalmorelikelyandcolonlesslikelytoclosevs.
smallbowel
PostoperativeECFmorelikelytoclosevs.other
cause
Lowoutputmorelikelytoclosevs.highoutput
Mortalityincreasedinhighoutputfistulas
 Mexico

174patientswithposoperativeECF,10years
Spontaneousclosure37%
Mortality13%
Location
SpontaneousClosure
Mortality
Classification DoesitReallyMatter?
Anatomy
SmallbowelECFslightlylesslikelytoclose
spontaneouslyandmaybeassociatedwith
highermortality
Etiology
Postoperativefistulamorelikelytoclose
spontaneouslybutmortalitysimilartoother
causes
Physiology
Highoutputfistulasarelesslikelytoclose
spontaneouslyandmaybeassociatedwith
highermortality
 Classification
Isthereabettersystem?
Superficialvs.deep
SuperficialECF
Drainsontoskinorgranulatingwound
Completelyextraperitonealprocess
Localwoundproblem,verylowmortality
DeepECF
Drainsintoperitonealcavity
Associatedwithperitonitis,sepsis,malnutrition
Highermortality
fistulainopenabdomen complicatedfistula
enteroatmosphericfistula
Deepvs.Superficial
 Denver!!

involvedstuffingmattressesintogapingholes,
extinguishinglocal,anddoggingdown watertightdoors
tolimitthespreadofdamage.Thesemeasureskeepthe
shipafloatandpermitassessmentofotherdamageand
timetoestablishaplanfordefinitiverepair.Theanalogyto
careoftheseriouslyinjuredisobvious.
 RiskofMortalityandFistulawith
OpenAbdomen
AUTHOR YEAR Pts MORTALITY DEVELOPEDECF
Barkeretal. 2007 258 67/258(26%)13/191(6.7%)
Jamshidietal. 2007 69 NR 7/69(10.1%)
MillerR.etal. 2005 344 68/344(20%) 10/276(3.6%)
Adkinsetal. 2004 81 20/81(25%) 12/61(19.7%)
Howdieshell 2004 88 17/88(19%) 0/71(0%)
Mayberry 2004 140 117/140(16%) 10/117(8.5%)
MillerP.etal. 2004 53 8/53(15%) 1/45(2.3%)
Tsueietal. 2004 71 23/55(42%) 14/55(27%)
Jerniganetal. 2003 274 108/274(39%) 10/166(6%)
Navsariaetal. 2003 55 25(45%) 3/30(10%)
MillerP.etal. 2002 148 65/148(44%) 1(0.7%)
Tremblayetal. 2001 181 81/181(45%) 26/100(26%)
Barkeretal. 2000 112 29/112(23%) 5/83(6%)
TOTAL 144 30%(1545%) 10.5%(027%)
Becker,ScandJSurg2007
 Netherlands
Mediantimetoclosure53days
Recurrenceaftersurgery9.3%
Mortality9.6%
Openabdomenmainnegativepredictorof
spontaneousclosure
Lowpreopalbumindecreasedspontaneous
closureandincreasedmortality
FistulaintheOpenAbdomen

692 36.5% 15.1%

323 4% 50%
 Multivariate=openabdomenandTPNwere
theonlyindependentpredictorsfor
spontaneousclosure
Spontaneousclosure5timeslesslikelyin
openabdomen
TPNincreasedrateofspontaneousclosureby
factorof5
 UK

277pts,10years
Overallhealingrate=69%
Conservativemanagement=50%(55/110)
Definitivesurgery=82%(137/167)
Mortality=15%
75%attributedtocomplicationoffistulaitself
 FistulaHealed
ConservativeManagement

OpenAbdomen=3timeslesslikelytoclose
Complexfistula=2timeslesslikelytoclose
Locationandetiologynoimpact
 SuccessfulSurgicalClosure

Onlyfistulacomplexityremainedsignificant
onmultivariateanalysis
Complexfistula4timeshigherrecurrence
thansimplefistula
WhenshouldIoperate?
 TimingofSurgery
Mediantimetorepair
=6months
RecurrenceRate
Operationb/t2and12
weeks=28%
Operationafter12
weeks=15%
Delayingsurgerymay
resultinlower
recurrence
Ann Surg 2004, Cleveland clinic
ReconstructAbdomen,too?